Healthcare Provider Details

I. General information

NPI: 1922501774
Provider Name (Legal Business Name): MRS. VERONICA NICHOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VERONICA VINE

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

1400 SW 5TH AVE STE 500
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8276
  • Fax: 503-494-2025
Mailing address:
  • Phone:
  • Fax: 503-346-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberDO228597
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: