1639684400 NPI number — MELINDA LEE HERBAUGH CONRAD MA PCA

Table of content: MELINDA LEE HERBAUGH CONRAD MA PCA (NPI 1639684400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639684400 NPI number — MELINDA LEE HERBAUGH CONRAD MA PCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONRAD
Provider First Name:
MELINDA
Provider Middle Name:
LEE HERBAUGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA PCA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639684400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 NE 53RD 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:
97213-2740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-662-9212
Provider Business Mailing Address Fax Number:
503-882-4564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1706 NE 53RD AVE
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:
97213-2740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-662-9212
Provider Business Practice Location Address Fax Number:
503-882-4564
Provider Enumeration Date:
12/02/2017

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: 101YM0800X , with the licence number:  MC60732136 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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