Provider Demographics
NPI:1083205074
Name:THAVORN, ALEXA NICOLE I (OD)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:NICOLE
Last Name:THAVORN
Suffix:I
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 NE 7TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3179
Mailing Address - Country:US
Mailing Address - Phone:714-478-2676
Mailing Address - Fax:
Practice Address - Street 1:11805 NW CEDAR FALLS DR STE 105
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-2780
Practice Address - Country:US
Practice Address - Phone:503-747-0265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4556152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist