1407592397 NPI number — MR. ELLIOTT LOUIS KOIVISTO NP

Table of content: MR. ELLIOTT LOUIS KOIVISTO NP (NPI 1407592397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407592397 NPI number — MR. ELLIOTT LOUIS KOIVISTO NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOIVISTO
Provider First Name:
ELLIOTT
Provider Middle Name:
LOUIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1407592397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11785 SW ROBBINS DR
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:
97008-7949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-522-2831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7145 SW VARNS ST STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-8168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-405-2584
Provider Business Practice Location Address Fax Number:
800-785-4531
Provider Enumeration Date:
05/12/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  AP61377025 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 10005745 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201390875RN . This is a "OREGON STATE NURSING LICENSE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: RN60545376 . This is a "WASHINGTON STATE DEPARTMENT OF HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AP61377025 . This is a "WASHINGTON STATE DEPARTMENT OF HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 10005745 . This is a "OREGON STATE NURSING LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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