Healthcare Provider Details

I. General information

NPI: 1336338441
Provider Name (Legal Business Name): CARRIE A VIEIRA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E 19TH ST
THE DALLES OR
97058
US

IV. Provider business mailing address

PO BOX 1520 1810 E 19TH ST
THE DALLES OR
97058-1520
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-7677
  • Fax: 541-296-7206
Mailing address:
  • Phone: 541-296-7677
  • Fax: 541-296-7206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-712
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA150314
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: