Healthcare Provider Details

I. General information

NPI: 1316339088
Provider Name (Legal Business Name): MAICA PUNZALAN DELA CRUZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

6255 SHERIDAN DR SUITE 304
WILLIAMSVILLE NY
14221-4836
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax: 503-666-1162
Mailing address:
  • Phone: 716-630-2587
  • Fax: 716-857-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018490
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number018490
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA188907
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: