NPIMap

Individual provider Active NPI

Marisa Jane Wickerath, MD

  • Family Medicine Physician
  • Forest Grove, OR
National Provider Identifier
1962088641
Registry record updated Oct 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
MD221260 Issued in OR
Practice address
1825 Maple St
Forest Grove, OR 97116-1939
Phone
(503) 357-2136
NPI assigned
Mar 22, 2021
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MD221260 OR Primary
Emergency Medicine Physician 207P00000X MD61556041 WA

Addresses

Primary practice location

1825 Maple St
Forest Grove, OR 97116-1939

Mailing address

1400 SW 5TH Ave Ste 500
Portland, OR 97201-5537

Other practice location 1

310 S Roosevelt St
Goldendale, WA 98620-9201
Phone (509) 773-4022

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA, OR2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20240718001571 WA Practitioner - Emergency Medicine 7810391703 Reassigns benefits to 2 organizations
I20240917003523 OR Practitioner - Family Practice 7810391703 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Washington School of Medicine, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Tuality Medical Group LLCGroup PAC ID 7416173414, 289 clinicians

Practice addresses (Care Compare)

335 SE 8TH Ave
Hillsboro, OR 97123-4246
Phone (503) 681-1111

Hospital & facility affiliations

  • Hillsboro Medical Center Hospital, Hillsboro, OR, CCN 380021
  • Ohsu Hospital and Clinics Hospital, Portland, OR, CCN 380009

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD221260ORMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
University Professional Services CurrentSince Sep 1, 2024 Accepting new patients
University Professional Services CurrentSince Sep 1, 2024 Accepting new patients
Tuality Medical Group LLC CurrentSince Sep 1, 2024 Accepting new patients
Klickitat County Public Hospital District No 1 Current Accepting new patients
Klickitat County Public Hospital District No 1 Current Accepting new patients
Klickitat County Public Hospital District No 1 CurrentSince Aug 1, 2024 Accepting new patients
Tuality Medical Group LLC CurrentSince Sep 1, 2024 Accepting new patients

Locations

15700 SW Greystone Ct
Beaverton, OR 97006
Phone (503) 203-1000

1825 Maple St
Forest Grove, OR 97116
Phone (503) 357-2136

335 SE 8th Ave
Hillsboro, OR 97123
Phone (503) 681-1111

1400 SW 5th Ave
Ste 500
Portland, OR 97201

3181 SW Sam Jackson Park Rd
Portland, OR 97239
Phone (503) 494-5674

310 S Roosevelt St
Goldendale, WA 98620
Phone (509) 486-2151

Interoperability endpoints

  • Direct secure messaging: mwickerath179446@direct.ohsu.edu

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 13

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1616371200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1729641600000",
    "number": "1962088641",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1400 SW 5TH AVE STE 500",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972015537",
            "fax_number": "503-346-8021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1825 MAPLE ST",
            "city": "FOREST GROVE",
            "state": "OR",
            "postal_code": "971161939",
            "telephone_number": "503-357-2136"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "310 S Roosevelt St",
            "address_purpose": "LOCATION",
            "city": "Goldendale",
            "state": "WA",
            "postal_code": "986209201",
            "country_code": "US",
            "telephone_number": "509-773-4022",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WICKERATH",
        "first_name": "MARISA",
        "middle_name": "JANE",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-03-22",
        "last_updated": "2024-10-23",
        "certification_date": "2024-10-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD221260",
            "primary": true
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "WA",
            "license": "MD61556041",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Forest Grove, OR

Sources for this page

Verify at the official NPI Registry.