Basic Information
Provider Information | |||||||||
NPI: | 1548518913 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAUFMAN | ||||||||
FirstName: | MIHAL | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 NE 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986641913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603973352 | ||||||||
FaxNumber: | 3606041771 | ||||||||
Practice Location | |||||||||
Address1: | 1750 THOMPSON RD | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974202100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412664402 | ||||||||
FaxNumber: | 5412676905 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2012 | ||||||||
LastUpdateDate: | 03/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 201406730 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 2014067NP-PP | 01 | OR | OREGON LICENSE | OTHER |