Provider Demographics
NPI:1154517175
Name:CUNNINGHAM, MICHAEL PATRIC (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRIC
Last Name:CUNNINGHAM
Suffix:
Gender:M
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 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:9250 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6721
Practice Address - Country:US
Practice Address - Phone:503-293-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant