Provider Demographics
NPI:1811086762
Name:MYKLEBUST, MONICA K (MD)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:K
Last Name:MYKLEBUST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:16180 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6301
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:503-582-4999
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081301207Q00000X
ORMD28074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR242654Medicaid
MI4505746Medicaid
MI0H17630096Medicare ID - Type Unspecified
ORR149797Medicare PIN
MIF84550Medicare UPIN