Basic Information
| Provider Information | |||||||||
| NPI: | 1609293174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTT | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N GRAHAM ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271683 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 N GRAHAM ST STE 580 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972272003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2014 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 166641 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA166641 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500675638 | 05 | OR | MEDICAID |