1447079298 NPI number — PNW NATURAL MEDICINE

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 1447079298 NPI number — PNW NATURAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PNW NATURAL MEDICINE
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:
Provider Other Organization Name Type Code:
6
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:
1447079298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15548 SW WINTERGREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-246-1382
Provider Business Mailing Address Fax Number:
503-213-6330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10110 SW NIMBUS AVE STE B3
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:
97223-4359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-213-5775
Provider Business Practice Location Address Fax Number:
503-213-6330
Provider Enumeration Date:
10/08/2024

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN-JOHNSON
Authorized Official First Name:
ALEXANDRIA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER, PHYSICIAN
Authorized Official Telephone Number:
971-361-6155

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500753165 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500753160 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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