Healthcare Provider Details

I. General information

NPI: 1063961373
Provider Name (Legal Business Name): ELISABETH ROMATZ MAHMUD RN, AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 NW SAMARITAN DR
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

444 NW ELKS DRIVE
CORVALLIS OR
97330
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1150
  • Fax:
Mailing address:
  • Phone: 541-754-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberNC60406565
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60689189
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number201701726NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: