1336298397 NPI number — MRS. MICHELLE ANN MURA JOHNSON OTRL

Table of content: MRS. MICHELLE ANN MURA JOHNSON OTRL (NPI 1336298397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336298397 NPI number — MRS. MICHELLE ANN MURA JOHNSON OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MURA JOHNSON
Provider First Name:
MICHELLE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURA
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336298397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1126
Provider Second Line Business Mailing Address:
610 HIGH STREET
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-8903
Provider Business Mailing Address Fax Number:
503-650-4302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 HIGH STREET
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-657-8903
Provider Business Practice Location Address Fax Number:
503-650-4302
Provider Enumeration Date:
01/09/2007

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: 225X00000X , with the licence number:  983676 , 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: 8397937 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 071477 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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