Healthcare Provider Details

I. General information

NPI: 1811428246
Provider Name (Legal Business Name): JO ANNE NIELSEN, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14279 S GLEN OAKS RD
OREGON CITY OR
97045-8008
US

IV. Provider business mailing address

14279 S GLEN OAKS RD
OREGON CITY OR
97045-8008
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-7632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD14362
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier128553
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: KIMBERLEE SCHLIMGEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-722-9833