Healthcare Provider Details

I. General information

NPI: 1396997292
Provider Name (Legal Business Name): MEGAN LOUISE HARLESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN LOUISE SURATT

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 VILLA RD
NEWBERG OR
97132-1881
US

IV. Provider business mailing address

308 VILLA RD
NEWBERG OR
97132-1881
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-9431
  • Fax: 503-538-2358
Mailing address:
  • Phone: 503-538-9431
  • Fax: 503-538-2358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1404
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: