Healthcare Provider Details

I. General information

NPI: 1619204583
Provider Name (Legal Business Name): GRETA KATHERINE LARSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETA KATHERINE MEYERS

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 NW DIVISION ST
GRESHAM OR
97030-5506
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201391240NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500660728
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: