Healthcare Provider Details

I. General information

NPI: 1396736518
Provider Name (Legal Business Name): WILLAMETTE GENERAL & COLON-RECTAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19875 SW 65TH AVE SUITE 260
TUALATIN OR
97062-8353
US

IV. Provider business mailing address

19875 SW 65TH AVE SUITE 260
TUALATIN OR
97062-8353
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-1743
  • Fax: 503-691-0983
Mailing address:
  • Phone: 503-691-1743
  • Fax: 503-691-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD20653
License Number StateOR

VIII. Authorized Official

Name: DR. BRENT K EVETTS
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 503-691-1743