Individual
MRS. MARY ANN CUSTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
18040 SW LOWER BOONES FERRY RD, SUITE 100, TIGARD, OR 97224-7258
(503) 216-0700
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
200850006NP
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
218626
—
OR
01
—
P00650720
RR MEDICARE
OR
Enumeration date
01/22/2008
Last updated
10/28/2012
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