Provider Demographics
NPI:1720060353
Name:O'CONNOR, STEPHANIE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MATUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1229 EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1435
Mailing Address - Country:US
Mailing Address - Phone:541-400-0367
Mailing Address - Fax:
Practice Address - Street 1:18750 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5330
Practice Address - Country:US
Practice Address - Phone:541-296-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450105NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
8945123OtherWA CRIME VICTIMS
WA9643768Medicaid
0223414OtherWA L&I
OR022961Medicaid
858543038OtherREGENCE BLUE CROSS
0223414OtherWA L&I
P48322Medicare UPIN