MEDICARE: MRS. ELIZABETH MARIE PANCOAST MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLPL4842	AZ
2	235Z00000X	Speech-Language Pathologist	016476	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	982597	OTHER	AZ	ACCESS

General Provider Information

NPI Number	:	1528192580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH MARIE PANCOAST MS

Provider Business Mailing Address
First Line	:	4029 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5341
Country	:	US
Telephone Number	:	415-583-3185
Fax Number	:

Provider Business Practice Location Address
First Line	:	4029 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5341
Country	:	US
Telephone Number	:	415-583-3185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/11/2022

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Directions to “ MRS. ELIZABETH MARIE PANCOAST MS” Practice Location

Language	Start Address	Practice Location

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