Provider Demographics
NPI:1124627054
Name:IDDRISU, MUSAH N (RN)
Entity type:Individual
Prefix:
First Name:MUSAH
Middle Name:N
Last Name:IDDRISU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 NW 6TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:
Practice Address - Street 1:12710 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3134
Practice Address - Country:US
Practice Address - Phone:503-988-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10017169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner