Healthcare Provider Details

I. General information

NPI: 1447705801
Provider Name (Legal Business Name): PURSUIT SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST STE 522
PORTLAND OR
97210-3033
US

IV. Provider business mailing address

3439 NE SANDY BLVD #234
PORTLAND OR
97232-1959
US

V. Phone/Fax

Practice location:
  • Phone: 971-302-7084
  • Fax: 503-286-7939
Mailing address:
  • Phone: 971-302-7084
  • Fax: 503-286-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberDO28084
License Number StateOR

VIII. Authorized Official

Name: PAUL W JOHNSON
Title or Position: OWNER
Credential: DO
Phone: 971-302-7084