1396204533 NPI number — BRENDA REBECCA IKWAP MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396204533 NPI number — BRENDA REBECCA IKWAP MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IKWAP
Provider First Name:
BRENDA
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1396204533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 NE 20TH AVE STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19250 SW 65TH AVE STE 235
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-7745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-692-5650
Provider Business Practice Location Address Fax Number:
503-692-7903
Provider Enumeration Date:
03/18/2019

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD221309 , 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: 2136113 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500765006 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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