Healthcare Provider Details

I. General information

NPI: 1043123466
Provider Name (Legal Business Name): MATTHEW R MCMULLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 NE GALLOWAY ST
MCMINNVILLE OR
97128-3933
US

IV. Provider business mailing address

2211 SW 1ST AVE UNIT 206
PORTLAND OR
97201-5012
US

V. Phone/Fax

Practice location:
  • Phone: 775-790-1548
  • Fax:
Mailing address:
  • Phone: 775-790-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: