Healthcare Provider Details

I. General information

NPI: 1467900423
Provider Name (Legal Business Name): MAKKEDAH-SATORI MARIELOVE EMANUEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 NW LOVEJOY ST
PORTLAND OR
97209-1503
US

IV. Provider business mailing address

PO BOX 2908
PORTLAND OR
97208-2908
US

V. Phone/Fax

Practice location:
  • Phone: 503-414-5661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA189964
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: