Healthcare Provider Details

I. General information

NPI: 1255151544
Provider Name (Legal Business Name): ASTIN MARY MILLS AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASTIN BUSH

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
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

16233 S CREEK HAVEN LN
BEAVERCREEK OR
97004-9694
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1520
  • Fax:
Mailing address:
  • Phone: 503-545-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number10033752
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10033752
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: