Healthcare Provider Details

I. General information

NPI: 1548749823
Provider Name (Legal Business Name): NATHAN EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/05/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 SW ANKENY STREET
PORTLAND OR
97214
US

IV. Provider business mailing address

668 SW FORESTA TER
PORTLAND OR
97225-7056
US

V. Phone/Fax

Practice location:
  • Phone: 971-236-7610
  • Fax:
Mailing address:
  • Phone: 806-670-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number62510
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: