Provider Demographics
NPI:1689727885
Name:FOOKSON, MAXINE MAY (PNP)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:MAY
Last Name:FOOKSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 SW STARK ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2347
Mailing Address - Country:US
Mailing Address - Phone:503-988-3674
Mailing Address - Fax:503-988-5183
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-3674
Practice Address - Fax:503-988-5183
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006458N2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS98081Medicare UPIN
OR106215Medicare ID - Type Unspecified