Basic Information
| Provider Information | |||||||||
| NPI: | 1013409135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRSE | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRUMMOND | ||||||||
| OtherFirstName: | MIRIAM | ||||||||
| OtherMiddleName: | MORIAH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2450 SW PERKINS AVE | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978014302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419666638 | ||||||||
| FaxNumber: | 5412788324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 SW PERKINS AVE | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978014302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419666638 | ||||||||
| FaxNumber: | 5412788324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2018 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA195713 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.