Healthcare Provider Details

I. General information

NPI: 1124627054
Provider Name (Legal Business Name): MUSAH N IDDRISU RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12710 SE DIVISION ST
PORTLAND OR
97236-3134
US

IV. Provider business mailing address

619 NW 6TH AVE FL 5
PORTLAND OR
97209-3964
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-3601
  • Fax:
Mailing address:
  • Phone: 503-988-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10017169
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: