Healthcare Provider Details

I. General information

NPI: 1417322017
Provider Name (Legal Business Name): MARY AGUILAR LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12045 SE STANLEY AVE
MILWAUKIE OR
97222-2938
US

IV. Provider business mailing address

8549 SE 29TH AVE
MILWAUKIE OR
97222-6316
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-2323
  • Fax:
Mailing address:
  • Phone: 503-200-9970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number07938
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: