Provider Demographics
NPI:1528129145
Name:SPOONER, PATRICIA M (CNM)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:SPOONER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST
Practice Address - Street 2:SUITE 114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1763
Practice Address - Country:US
Practice Address - Phone:503-215-6262
Practice Address - Fax:503-234-5437
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083044892N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291677Medicaid
OR291677Medicaid