Basic Information
| Provider Information | |||||||||
| NPI: | 1063725703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VACARELLA | ||||||||
| FirstName: | MARIA | ||||||||
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| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972121112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037754931 | ||||||||
| FaxNumber: | 5037887285 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 NE DIVISION ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037754931 | ||||||||
| FaxNumber: | 5037887285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 201050134NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 500624036 | 05 | OR | MEDICAID |