Basic Information
| Provider Information | |||||||||
| NPI: | 1083036990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILLARD | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IWATA | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1027 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10822 SE 82ND AVE | ||||||||
| Address2: | |||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2014 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201142492RN | OR | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 201705362NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.