Provider Demographics
NPI:1912709510
Name:WEST, MYRANDA (PWS)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:WEST
Suffix:
Gender:
Credentials:PWS
Other - Prefix:
Other - First Name:CHARLEY
Other - Middle Name:
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PWS
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:509-224-1044
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000109640175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist