Healthcare Provider Details

I. General information

NPI: 1649239278
Provider Name (Legal Business Name): PAMELA J PHELAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA J CROSSEN

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 01/26/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6958 SW VARNS STREET SOUTHWEST DIAGNOSTIC IMAGING, LTD
PORTLAND OR
97223-2530
US

IV. Provider business mailing address

6958 SW VARNS STREET SOUTHWEST DIAGNOSTIC IMAGING, LTD
PORTLAND OR
97223-2530
US

V. Phone/Fax

Practice location:
  • Phone: 503-683-7730
  • Fax: 39-140-9275
Mailing address:
  • Phone: 503-683-7730
  • Fax: 39-140-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3302
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA203665
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: