Healthcare Provider Details

I. General information

NPI: 1174488787
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF THE NORTHWEST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 SW DARTMOUTH ST
TIGARD OR
97223-7614
US

IV. Provider business mailing address

7150 SW DARTMOUTH ST
TIGARD OR
97223-7614
US

V. Phone/Fax

Practice location:
  • Phone: 503-968-3480
  • Fax: 503-227-4589
Mailing address:
  • Phone: 503-968-3480
  • Fax: 503-227-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL EWANCHUK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 503-227-0671