Provider Demographics
NPI:1912906405
Name:VANALLEN, MICHAEL R (M D P C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:VANALLEN
Suffix:
Gender:M
Credentials:M D P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 SW 65TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7451
Mailing Address - Country:US
Mailing Address - Phone:503-692-8907
Mailing Address - Fax:503-612-0524
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-692-8907
Practice Address - Fax:503-612-0524
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-08-20
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
ORMD15401174400000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-1209679OtherMEDICARE
OR0000BLBWMMedicare ID - Type Unspecified