Basic Information
Provider Information | |||||||||
NPI: | 1639375405 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STICKER | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 847 NE 19TH AVE STE 300 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972322686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039632801 | ||||||||
FaxNumber: | 5039632825 | ||||||||
Practice Location | |||||||||
Address1: | 4805 NE GLISAN ST STE 6N60 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972132933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032155526 | ||||||||
FaxNumber: | 5034167377 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2007 | ||||||||
LastUpdateDate: | 03/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA194156 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X |   | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 500605459 | 05 | OR |   | MEDICAID | 2000682 | 05 | WA |   | MEDICAID |