Healthcare Provider Details

I. General information

NPI: 1124166244
Provider Name (Legal Business Name): MICHAEL J NOONAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9495 SW LOCUST ST STE A
PORTLAND OR
97223-6683
US

IV. Provider business mailing address

9495 SW LOCUST ST STE A
PORTLAND OR
97223-6683
US

V. Phone/Fax

Practice location:
  • Phone: 503-636-9011
  • Fax: 503-636-3952
Mailing address:
  • Phone: 503-636-9011
  • Fax: 503-636-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD06672
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: