1417909094 NPI number — DR. ANGELA STOCK NAIRN MD

Table of content: DR. ANGELA STOCK NAIRN MD (NPI 1417909094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417909094 NPI number — DR. ANGELA STOCK NAIRN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAIRN
Provider First Name:
ANGELA
Provider Middle Name:
STOCK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STOCK
Provider Other First Name:
ANGELA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1417909094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 EXCHANGE ST
Provider Second Line Business Mailing Address:
STE 190
Provider Business Mailing Address City Name:
ASTORIA
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97103-3419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-325-5300
Provider Business Mailing Address Fax Number:
503-325-5400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2055 EXCHANGE ST
Provider Second Line Business Practice Location Address:
STE 190
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-325-5300
Provider Business Practice Location Address Fax Number:
503-325-5400
Provider Enumeration Date:
05/16/2006

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: 207Q00000X , with the licence number:  MD22457 , 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: 288188 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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