1265749188 NPI number — STEPHANIE WARYE MPAS, PA-C

Table of content: STEPHANIE WARYE MPAS, PA-C (NPI 1265749188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265749188 NPI number — STEPHANIE WARYE MPAS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARYE
Provider First Name:
STEPHANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPAS, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENJAMIN
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPAS PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265749188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 NW 13TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97209-2953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-684-8252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2228 NW PETTYGROVE ST STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
32-885-2015
Provider Business Practice Location Address Fax Number:
503-288-0151
Provider Enumeration Date:
09/13/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA153224 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MA054088 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA153224 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500647021 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".