Basic Information
| Provider Information | |||||||||
| NPI: | 1851637383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARGETT | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | SOPHIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 NW 6TH AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972093964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038875665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12710 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972363134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2013 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/29/2018 | ||||||||
| NPIReactivationDate: | 04/11/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201802206NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201802206NP | 01 | OR | STATE LICENSE | OTHER |