1861656621 NPI number — ALISSA ZEA MCMAKEN ROBERTS CNM

Table of content: ALISSA ZEA MCMAKEN ROBERTS CNM (NPI 1861656621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861656621 NPI number — ALISSA ZEA MCMAKEN ROBERTS CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMAKEN ROBERTS
Provider First Name:
ALISSA
Provider Middle Name:
ZEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCMAKEN
Provider Other First Name:
ALISSA
Provider Other Middle Name:
ZEA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861656621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7650 SW BEVELAND RD STE 200
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:
97223-8692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-601-3615
Provider Business Mailing Address Fax Number:
503-646-1683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1508 DIVISION ST
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-657-1071
Provider Business Practice Location Address Fax Number:
503-657-3321
Provider Enumeration Date:
07/10/2008

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: 176B00000X , with the licence number:  200850069NP NMNP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: 200850069 , 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: 200850069NP NMNP . This is a "CNM LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 279287 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200242145RN . This is a "RN LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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