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NPI Code Detail

MEDICARE: ALAN K MIRLY PA

MEDICARE: ALAN K MIRLY PA
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
1363A00000XPhysician AssistantPA-558ID
2363A00000XPhysician AssistantPA60997082WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3PAWV4OTHERIDBLUE CROSS

General Provider Information

NPI Number : 1891780524
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALAN K MIRLY PA
Provider Business Mailing Address
First Line : PO BOX 4825
Second Line :
City : PORTLAND
State : OR
Zip : 97208-4825
Country : US
Telephone Number : 360-882-2778
Fax Number : 360-604-1771
Provider Business Practice Location Address
First Line : 2525 NE 139TH ST STE 220
Second Line :
City : VANCOUVER
State : WA
Zip : 98686-2719
Country : US
Telephone Number : 360-882-2778
Fax Number : 360-604-1616
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/19/2005
Last Update Date : 12/09/2019

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1215924055 — DR. CRAIG CHARLES NEWLAND M.D.
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1356320402 — CYNTHIA M ASHBAUGH FNP
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Directions to “ ALAN K MIRLY PA” Practice Location

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