Healthcare Provider Details

I. General information

NPI: 1558798975
Provider Name (Legal Business Name): ALIX L WHERLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD MAIL CODE: L352A
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

2250 NW KEARNEY ST APT 413
PORTLAND OR
97210-3058
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7824
  • Fax: 503-494-0441
Mailing address:
  • Phone: 503-924-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA163453
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: