Healthcare Provider Details

I. General information

NPI: 1710298385
Provider Name (Legal Business Name): BRIAN WARNER BLAIR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 04/13/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16144 SE HAPPY VALLEY TOWN CENTER DR STE 210
HAPPY VALLEY OR
97086-4257
US

IV. Provider business mailing address

16144 SE HAPPY VALLEY TOWN CENTER DR STE 210
HAPPY VALLEY OR
97086-4257
US

V. Phone/Fax

Practice location:
  • Phone: 503-486-7040
  • Fax: 503-658-3377
Mailing address:
  • Phone: 503-486-7040
  • Fax: 503-658-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD162295
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500661973
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: