Healthcare Provider Details

I. General information

NPI: 1083924948
Provider Name (Legal Business Name): JUDY ELLEN FLYNN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 SW CEDAR HILLS BLVD
BEAVERTON OR
97005
US

IV. Provider business mailing address

85 NORTH 12TH STREET PO BOX 568
CORNELIUS OR
97113
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-8562
  • Fax: 503-352-7089
Mailing address:
  • Phone: 503-352-8562
  • Fax: 503-352-7089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00428
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00428
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: