Basic Information
| Provider Information | |||||||||
| NPI: | 1265497655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OHARA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5319 SW WESTGATE DR | ||||||||
| Address2: | #241 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032977223 | ||||||||
| FaxNumber: | 5032977603 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 SW 9TH ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418817140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 096007764 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 004380200 | 05 | ID | MEDICAID | 006401009 | 01 | OR | REGENCE BCBSO | OTHER | 292410 | 05 | OR | MEDICAID |