Healthcare Provider Details

I. General information

NPI: 1699697755
Provider Name (Legal Business Name): BRNJAMIN ELLISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16365 NW TWIN OAKS DR STE 200
BEAVERTON OR
97006
US

IV. Provider business mailing address

16365 NW TWIN OAKS DR STE 200
BEAVERTON OR
97006
US

V. Phone/Fax

Practice location:
  • Phone: 503-828-3042
  • Fax:
Mailing address:
  • Phone: 503-828-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: