Provider Demographics
NPI:1659091312
Name:PAOLO, MANDY N (PA-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:N
Last Name:PAOLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:N
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2730 S MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2435 NE CUMULUS AVE STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8805
Practice Address - Country:US
Practice Address - Phone:503-472-6161
Practice Address - Fax:503-434-6290
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA222386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA222386OtherLICENSE