Healthcare Provider Details

I. General information

NPI: 1336501584
Provider Name (Legal Business Name): JOHN AVERY THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 08/10/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD STE 420
PORTLAND OR
97225-6631
US

IV. Provider business mailing address

9155 SW BARNES RD STE 420
PORTLAND OR
97225-6631
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-6334
  • Fax:
Mailing address:
  • Phone: 503-297-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberMD192172
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD192172
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: