Provider Demographics
NPI:1083327951
Name:WILLOW, EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:WILLOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 NW CLAYPOOL ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1842
Mailing Address - Country:US
Mailing Address - Phone:541-447-6627
Mailing Address - Fax:
Practice Address - Street 1:240 NW CLAYPOOL ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1842
Practice Address - Country:US
Practice Address - Phone:541-447-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty