Provider Demographics
NPI:1487611380
Name:STAHLY, MICHAEL L (FNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:STAHLY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 NE CUSHING DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3887
Mailing Address - Country:US
Mailing Address - Phone:541-388-2333
Mailing Address - Fax:
Practice Address - Street 1:1303 NE CUSHING DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3730
Practice Address - Country:US
Practice Address - Phone:541-330-8226
Practice Address - Fax:541-318-0373
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200540385RN163W00000X
OR200550022NP363LA2100X
OR200550023NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00414327OtherRAILROAD MEDICARE
OR079934Medicaid
ORP00414327OtherRAILROAD MEDICARE
OR079934Medicaid