Basic Information
| Provider Information | |||||||||
| NPI: | 1457953648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNSELL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BRADLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10763 SW GREENBURG RD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972235492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848159 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10763 SW GREENBURG RD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972235492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848159 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 202007175LPN | OR | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.