=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801698840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY MEYER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2025
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9205 SW BARNES RD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-216-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3218 OREGON AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63118-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-401-2949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 10033138
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------