MEDICARE: MRS. EVONNE MARIA KANDAS N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	089000443N7	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689677445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EVONNE MARIA KANDAS N.P.

Provider Business Mailing Address
First Line	:	1130 NW 22ND AVE
Second Line	:	SUITE 110
City	:	PORTLAND
State	:	OR
Zip	:	97210-2900
Country	:	US
Telephone Number	:	503-413-8654
Fax Number	:	503-413-8655

Provider Business Practice Location Address
First Line	:	1130 NW 22ND AVE
Second Line	:	SUITE 110
City	:	PORTLAND
State	:	OR
Zip	:	97210-2900
Country	:	US
Telephone Number	:	503-413-8654
Fax Number	:	503-413-8655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	04/21/2017

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