Healthcare Provider Details

I. General information

NPI: 1063185478
Provider Name (Legal Business Name): PNW PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

IV. Provider business mailing address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

V. Phone/Fax

Practice location:
  • Phone: 503-749-5512
  • Fax:
Mailing address:
  • Phone: 503-749-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
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: LEO J URBINELLI
Title or Position: OWNER
Credential: MD
Phone: 503-749-5512