Provider Demographics
NPI:1124890066
Name:ESCOBAR MANRIQUEZ, MIRIAM (THW)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:ESCOBAR MANRIQUEZ
Suffix:
Gender:F
Credentials:THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-5700
Mailing Address - Fax:503-418-5704
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-5700
Practice Address - Fax:503-418-5704
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR109835172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker