Healthcare Provider Details

I. General information

NPI: 1336596113
Provider Name (Legal Business Name): AT HOME PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 MAIN ST SUITE 112
OREGON CITY OR
97045-1830
US

IV. Provider business mailing address

PO BOX 945
LAKE OSWEGO OR
97034-0103
US

V. Phone/Fax

Practice location:
  • Phone: 503-344-6717
  • Fax: 503-345-9867
Mailing address:
  • Phone: 503-344-6717
  • Fax: 503-345-9867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number200650008NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number200650008NP
License Number StateOR

VIII. Authorized Official

Name: MONICA FERGUSON
Title or Position: CEO
Credential: NP
Phone: 503-358-7908