1255500203 NPI number — DR KATIE EVANS INC

Table of content: (NPI 1255500203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255500203 NPI number — DR KATIE EVANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR KATIE EVANS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVANS & SULLIVAN
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255500203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19943 SW JETTE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97006-2789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-756-6117
Provider Business Mailing Address Fax Number:
503-524-3778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19943 SW JETTE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97006-2789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-756-6117
Provider Business Practice Location Address Fax Number:
503-524-3778
Provider Enumeration Date:
02/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
KATIE
Authorized Official Middle Name:
EVANS
Authorized Official Title or Position:
TREATMENT DIRECTOR CEO
Authorized Official Telephone Number:
503-756-6117

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  860106 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: CP00004591 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1615-01 . This is a "PBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100000012349 . This is a "REGENCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 0001152747 . This is a "MHN SERVICES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 283365 . This is a "MULTIPLAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 669401100000 . This is a "LIFEWISE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 3006890 . This is a "REGENCE BLUECROSS BLUESHIELD OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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