Healthcare Provider Details

I. General information

NPI: 1740643337
Provider Name (Legal Business Name): ELAINE WYNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9169 SW BURNHAM ST
TIGARD OR
97223-6105
US

IV. Provider business mailing address

9169 SW BURNHAM ST
TIGARD OR
97223-6105
US

V. Phone/Fax

Practice location:
  • Phone: 503-639-5115
  • Fax: 503-624-0542
Mailing address:
  • Phone: 503-639-5115
  • Fax: 503-624-0542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4193ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: