Provider Demographics
NPI:1093357378
Name:EVANETICH, CASSANDRA (PA)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:EVANETICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 MOUNTAIN VIEW LN STE 200
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2894
Mailing Address - Country:US
Mailing Address - Phone:503-359-4773
Mailing Address - Fax:503-359-3809
Practice Address - Street 1:1909 MOUNTAIN VIEW LN STE 200
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2894
Practice Address - Country:US
Practice Address - Phone:503-359-4773
Practice Address - Fax:503-359-3809
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA195867363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500753082Medicaid