Healthcare Provider Details

I. General information

NPI: 1831054436
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF THE NORTHWEST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 NW VAUGHN ST
PORTLAND OR
97210-5311
US

IV. Provider business mailing address

2701 NW VAUGHN ST STE 360
PORTLAND OR
97210-5376
US

V. Phone/Fax

Practice location:
  • Phone: 503-227-0671
  • Fax: 503-227-0676
Mailing address:
  • Phone: 503-227-0617
  • Fax: 503-227-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL EWANCHUK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 503-227-0671