Healthcare Provider Details

I. General information

NPI: 1063094621
Provider Name (Legal Business Name): ALMA SAN JUAN AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25050 SE STARK ST STE 265
GRESHAM OR
97030-3388
US

IV. Provider business mailing address

25050 SE STARK ST STE 265
GRESHAM OR
97030-3388
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number202008006
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: