Basic Information
| Provider Information | |||||||||
| NPI: | 1770755571 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC HEART ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CARDIAC CONSULTANTS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | SUITE 660 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037901234 | ||||||||
| FaxNumber: | 5037900234 | ||||||||
| Practice Location | |||||||||
| Address1: | 967 N CASCADE DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970713140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036920405 | ||||||||
| FaxNumber: | 5036927978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAZRINE | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5037901234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 287001 | 05 | OR | MEDICAID |