Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003479296 |
---|---|
Provider Name | Alyssa J Distor |
First Address | Portland, OR 97202-2345 |
Second Address | Portland, OR 97202-2345 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2019 |
Last Update Date | 15/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
54023227 | KAISER PERMANENTE (01) | OR |