Healthcare Provider Details

I. General information

NPI: 1225387129
Provider Name (Legal Business Name): KEITH PAPPAS POULSEN DVM, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SW 30TH ST
CORVALLIS OR
97331-8628
US

IV. Provider business mailing address

700 SW 30TH ST
CORVALLIS OR
97331-8628
US

V. Phone/Fax

Practice location:
  • Phone: 608-338-6444
  • Fax:
Mailing address:
  • Phone: 608-338-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5662
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: