=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104528660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY M WEIS RN, ADN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2023
-----------------------------------------------------
Last Update Date | 03/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 335 SE 8TH AVE
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-4246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-681-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18763 S GRASLE RD
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-8899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-388-8687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | 202107666RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------