Provider Demographics
NPI:1831917707
Name:REITER, MICAH LUNA
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:LUNA
Last Name:REITER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:LUNA
Other - Last Name:REITER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3425 SW US VETERANS HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2941
Mailing Address - Country:US
Mailing Address - Phone:503-459-9808
Mailing Address - Fax:
Practice Address - Street 1:3425 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2941
Practice Address - Country:US
Practice Address - Phone:503-459-9808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10033619163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program