Healthcare Provider Details

I. General information

NPI: 1942319140
Provider Name (Legal Business Name): THERESA NMI MOLLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA NMI MOLLER PA

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

IV. Provider business mailing address

22825 SW 93RD TER
TUALATIN OR
97062-7302
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-7565
  • Fax:
Mailing address:
  • Phone: 503-691-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00370
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: