Provider Demographics
NPI:1457743478
Name:MCNULTY, EILEEN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 NW LOVEJOY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2865
Mailing Address - Country:US
Mailing Address - Phone:503-223-1933
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2865
Practice Address - Country:US
Practice Address - Phone:503-223-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA177262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant