=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629421805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2043 COLLEGE WAY
-----------------------------------------------------
City | FOREST GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97116-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-722-8648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2043 COLLEGE WAY
-----------------------------------------------------
City | FOREST GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97116-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-352-2896
-----------------------------------------------------
Fax | 971-266-2993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE OFFICER
-----------------------------------------------------
Name | LISA DOWNING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-352-2663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD157616
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------