Provider Demographics
NPI:1750899035
Name:SANTIAM MOBILE MEDICINE LLC
Entity type:Organization
Organization Name:SANTIAM MOBILE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LULAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP
Authorized Official - Phone:503-507-5356
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-0118
Mailing Address - Country:US
Mailing Address - Phone:503-507-5356
Mailing Address - Fax:866-225-1708
Practice Address - Street 1:41805 STAYTON SCIO RD SE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-9739
Practice Address - Country:US
Practice Address - Phone:503-507-5356
Practice Address - Fax:866-225-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-20
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673258Medicaid
OR500779652Medicaid