Healthcare Provider Details

I. General information

NPI: 1689739575
Provider Name (Legal Business Name): EVONNE N SERPA AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 NE TILLAMOOK ST
PORTLAND OR
97213-1315
US

IV. Provider business mailing address

4311 NE TILLAMOOK ST
PORTLAND OR
97213-1315
US

V. Phone/Fax

Practice location:
  • Phone: 503-774-3668
  • Fax: 503-774-7247
Mailing address:
  • Phone: 503-774-3668
  • Fax: 503-774-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number22183
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-806697
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: