Provider Demographics
NPI:1053703504
Name:MEDRANO, CYNTHIA (PMHNP, FNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 NE HALSEY ST
Mailing Address - Street 2:BLDG 1, STE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:
Practice Address - Street 1:4400 NE HALSEY ST
Practice Address - Street 2:BLDG 1, STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-215-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID61328363LP0808X, 363LF0000X
OR201802878NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3545469-01Medicaid
TXAP127533OtherLICENSE
TX476566YMP3Medicare UPIN