Provider Demographics
NPI:1699931147
Name:MITCHUM, MARIE A
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:MITCHUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:R
Other - Last Name:MITCHUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1130 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4126
Mailing Address - Country:US
Mailing Address - Phone:503-325-1030
Mailing Address - Fax:
Practice Address - Street 1:1130 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4126
Practice Address - Country:US
Practice Address - Phone:503-325-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNOT REQUIRED1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295686Medicaid
WA9056722Medicaid
OR041635000OtherBLUE CROSS BLUE SHIELD
OR295686Medicaid