Healthcare Provider Details

I. General information

NPI: 1669715611
Provider Name (Legal Business Name): BLAIR LITTLETON HULETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BLAIR LOUISE LITTLETON

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 PACIFIC AVE
FOREST GROVE OR
97116-2224
US

IV. Provider business mailing address

3838 PACIFIC AVE
FOREST GROVE OR
97116-2224
US

V. Phone/Fax

Practice location:
  • Phone: 503-992-0288
  • Fax:
Mailing address:
  • Phone: 503-992-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA160875
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: