Provider Demographics
NPI:1366896581
Name:WULFF, COLLIN ANDREW (DO (STUDENT))
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:ANDREW
Last Name:WULFF
Suffix:
Gender:M
Credentials:DO (STUDENT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 SE HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5543
Mailing Address - Country:US
Mailing Address - Phone:541-990-1194
Mailing Address - Fax:
Practice Address - Street 1:1046 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1916
Practice Address - Country:US
Practice Address - Phone:541-812-4081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125072358207P00000X
390200000X
ORDO203088207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty