Provider Demographics
NPI:1861432163
Name:MOULTON-MISTER, AMBER (PA-C)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MOULTON-MISTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 SE 89TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2052
Mailing Address - Country:US
Mailing Address - Phone:503-788-6483
Mailing Address - Fax:503-772-7914
Practice Address - Street 1:2448 SE 89TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2052
Practice Address - Country:US
Practice Address - Phone:503-788-6483
Practice Address - Fax:503-772-7914
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004679363A00000X
NM2010-0006363A00000X
OR159703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA499847420AMedicaid
GA97WCHDKOtherMEDICARE-TYPE UNSPECIFIED
OR500652768Medicaid
GA97WCHDKOtherMEDICARE-TYPE UNSPECIFIED
OR2021979879Medicare NSC