Healthcare Provider Details

I. General information

NPI: 1528155280
Provider Name (Legal Business Name): LISA MARIE NEWTON-KLUCEVEK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 SW BARNES RD STE 100
PORTLAND OR
97225-6642
US

IV. Provider business mailing address

9250 SW HALL BLVD
TIGARD OR
97223
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-9560
  • Fax: 503-292-9510
Mailing address:
  • Phone: 503-293-0161
  • Fax: 503-221-4451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO21207
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0021207
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: