Healthcare Provider Details

I. General information

NPI: 1457663015
Provider Name (Legal Business Name): BETHANY JEAN LANE MOYSES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2010
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD P3-EYE
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

2697 NE OVERLOOK DR APT 1617
HILLSBORO OR
97124-7664
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 503-336-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3363ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: