Basic Information
| Provider Information | |||||||||
| NPI: | 1881870327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICH | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | MERYL | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICH-JOHNSON | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | MERYL | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036503110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37400 BELL ST | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970557868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036683483 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2008 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA15644 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.