Healthcare Provider Details

I. General information

NPI: 1790182392
Provider Name (Legal Business Name): TERRYOL BRANDON NOALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12518 NE AIRPORT WAY STE 110
PORTLAND OR
97230-1090
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 503-256-2992
  • Fax: 503-258-0717
Mailing address:
  • Phone: 541-220-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A15368
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO202311
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: