Healthcare Provider Details

I. General information

NPI: 1013513472
Provider Name (Legal Business Name): WILDWOOD HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16100 NW CORNELL RD STE 220
BEAVERTON OR
97006-7334
US

IV. Provider business mailing address

4906 NE CLEVELAND AVE
PORTLAND OR
97211-2718
US

V. Phone/Fax

Practice location:
  • Phone: 303-929-8993
  • Fax:
Mailing address:
  • Phone: 303-929-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLISON RENEE ROTT
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 303-929-8993