Provider Demographics
NPI:1962183293
Name:EMMONS, PAUL MICHAEL (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:EMMONS
Suffix:
Gender:M
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:HEPPNER
Mailing Address - State:OR
Mailing Address - Zip Code:97836-0469
Mailing Address - Country:US
Mailing Address - Phone:541-676-9161
Mailing Address - Fax:541-676-5662
Practice Address - Street 1:39 SE COURT AVE STE 202
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2228
Practice Address - Country:US
Practice Address - Phone:541-862-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1396592663Medicaid