Healthcare Provider Details

I. General information

NPI: 1306412812
Provider Name (Legal Business Name): IRYNA V EWBANK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3086 MEMORY LN
EUGENE OR
97404-1838
US

IV. Provider business mailing address

500 SUMMER ST NE # E-86
SALEM OR
97301-1064
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-1930
  • Fax:
Mailing address:
  • Phone: 503-945-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: