Healthcare Provider Details

I. General information

NPI: 1710098397
Provider Name (Legal Business Name): JOHN WIEST JR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

9900 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9777
US

V. Phone/Fax

Practice location:
  • Phone: 503-786-8435
  • Fax:
Mailing address:
  • Phone: 503-571-8631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberOR 078040891N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: