Basic Information
| Provider Information | |||||||||
| NPI: | 1841797990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VITEK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3417 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083417 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1475 MOUNT HOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970719066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9719835360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 58246 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 202010842NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1518377019 | 05 | ID | MEDICAID | 500787852 | 05 | OR | MEDICAID |