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General NPI Number Information
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NPI Number | 1144343773
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Entity Type | Organization
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Legal Business Name | EVERGREEN PEDIATRIC CLINIC PS
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 02/21/2020
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Provider Practice Location Address
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Address Line | 505 NE 87TH AVE STE 120
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City | VANCOUVER
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State | WA
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Zip | 98664-1989
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Country | US
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Telephone | 360-892-1635
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Fax | 360-892-3146
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Provider Business Mailing Address
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Address Line | 505 NE 87TH AVE STE 120
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City | VANCOUVER
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State | WA
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Zip | 98664-1989
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Country | US
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Telephone | 360-892-1635
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Fax | 360-892-3146
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TERI BRYANT
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Credential |
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Telephone | 360-892-1635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 601 115 723
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License Number State | WA
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