Provider Demographics
NPI:1942319140
Name:MOLLER, THERESA NMI (PA)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:NMI
Last Name:MOLLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:NMI
Other - Last Name:MOLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:22825 SW 93RD TER
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7302
Mailing Address - Country:US
Mailing Address - Phone:503-691-1006
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-643-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant