Healthcare Provider Details

I. General information

NPI: 1508979550
Provider Name (Legal Business Name): MICHAEL REAGAN SLAUGHTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD OPERATIVE CARE DIVISION: ORTHO
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

6380 NE CHERRY DR UNIT 619
HILLSBORO OR
97124-7457
US

V. Phone/Fax

Practice location:
  • Phone: 803-220-8262
  • Fax:
Mailing address:
  • Phone: 803-543-9435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102494
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002969
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number175136
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: