Healthcare Provider Details

I. General information

NPI: 1912906405
Provider Name (Legal Business Name): MICHAEL R VANALLEN M D P C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date: 03/18/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

19255 SW 65TH AVE SUITE 210
TUALATIN OR
97062-7451
US

IV. Provider business mailing address

19255 SW 65TH AVE SUITE 210
TUALATIN OR
97062-7451
US

V. Phone/Fax

Practice location:
  • Phone: 503-692-8907
  • Fax: 503-612-0524
Mailing address:
  • Phone: 503-692-8907
  • Fax: 503-612-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD15401
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberMD15401
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: