Healthcare Provider Details

I. General information

NPI: 1659908143
Provider Name (Legal Business Name): ALYSSA ELIZABETH MOORE WICKNICK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 NE STUCKI AVE
HILLSBORO OR
97124-5806
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2031
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 800-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDO220263
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDO.OP.70119031
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: