Healthcare Provider Details

I. General information

NPI: 1891972865
Provider Name (Legal Business Name): MARY ANN CUSTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 10/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18040 SW LOWER BOONES FERRY RD SUITE 100
TIGARD OR
97224-7258
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200850006NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: