Provider Demographics
NPI:1679734719
Name:SELIS, HEATHER CONROY (PNP)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:CONROY
Last Name:SELIS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:CONROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5050 NE HOYT ST.
Mailing Address - Street 2:SUITE B55
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2984
Mailing Address - Country:US
Mailing Address - Phone:503-233-5393
Mailing Address - Fax:503-659-8984
Practice Address - Street 1:5050 NE HOYT ST.
Practice Address - Street 2:SUITE B55
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2984
Practice Address - Country:US
Practice Address - Phone:503-233-5393
Practice Address - Fax:503-659-8984
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR93006586NZ2080A0000X
OR093006586N2208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500639814Medicaid