Healthcare Provider Details

I. General information

NPI: 1427029537
Provider Name (Legal Business Name): PHYLLIS DESHUN HURSEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 SE 11TH AVE
PORTLAND OR
97214-3601
US

IV. Provider business mailing address

13215 SE MILL PLAIN BLVD STE C8
VANCOUVER WA
98684-6999
US

V. Phone/Fax

Practice location:
  • Phone: 503-389-1166
  • Fax: 503-389-1161
Mailing address:
  • Phone: 503-269-2409
  • Fax: 503-389-1161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD26240
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMD26240
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: