Provider Demographics
NPI:1881274249
Name:BUNCKE, MICHELLE JEANNE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEANNE
Last Name:BUNCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 SW GIBBS ST UNIT 302
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-7327
Mailing Address - Country:US
Mailing Address - Phone:503-680-0173
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORSTUDENT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine