Provider Demographics
NPI:1003111790
Name:EWING, ERIC WESLEY (LMT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WESLEY
Last Name:EWING
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5845 NE HOYT ST APT 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3781
Mailing Address - Country:US
Mailing Address - Phone:707-672-4123
Mailing Address - Fax:
Practice Address - Street 1:5845 NE HOYT ST APT 204
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3781
Practice Address - Country:US
Practice Address - Phone:707-672-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16627172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker