Provider Demographics
NPI:1164478780
Name:PACIFIC VASCULAR SPECIALISTS PC
Entity Type:Organization
Organization Name:PACIFIC VASCULAR SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WIEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-289-2968
Mailing Address - Street 1:PO BOX 3571
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3571
Mailing Address - Country:US
Mailing Address - Phone:707-289-2968
Mailing Address - Fax:503-719-8253
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 321
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:707-289-2968
Practice Address - Fax:503-719-8253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD144742086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278874Medicaid
ORR109778OtherPTAN
ORR109778OtherPTAN