Basic Information
Provider Information | |||||||||
NPI: | 1912941667 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORAN | ||||||||
FirstName: | GAYLE | ||||||||
MiddleName: | MARGARET | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ADULT NURSE PRACTITI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORAN | ||||||||
OtherFirstName: | GAYLE | ||||||||
OtherMiddleName: | MARGARET | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ANP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5100 SW MACADAM AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972396102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9712025500 | ||||||||
FaxNumber: | 9712025555 | ||||||||
Practice Location | |||||||||
Address1: | 5100 SW MACADAM AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972396102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9712025500 | ||||||||
FaxNumber: | 9712025555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2006 | ||||||||
LastUpdateDate: | 01/23/2013 | ||||||||
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 | 363LP2300X | 098006088N3 ANP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 287406 | 05 | OR |   | MEDICAID | GM01 067593003 | 01 | OR | BLUE CROSS/SHIELD PIN | OTHER |