Healthcare Provider Details

I. General information

NPI: 1881870327
Provider Name (Legal Business Name): ROBERTA MERYL RICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROBERTA MERYL RICH-JOHNSON PA-C

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37400 BELL ST
SANDY OR
97055-7868
US

IV. Provider business mailing address

2051 KAEN RD
OREGON CITY OR
97045-4035
US

V. Phone/Fax

Practice location:
  • Phone: 503-668-3483
  • Fax:
Mailing address:
  • Phone: 503-650-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: