MEDICARE: PRISCILLA W LATTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD151051	OR
2	2083P0011X	Undersea and Hyperbaric Medicine (Preventive Medicine) Physician	MD151051	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639154974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISCILLA W LATTA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1188
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97339-1188
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 HICKORY ST NW STE 101
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97321-1700
Country	:	US
Telephone Number	:	541-812-3360
Fax Number	:	541-812-4499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	10/29/2020

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