Provider Demographics
NPI:1407592397
Name:KOIVISTO, ELLIOTT LOUIS (NP)
Entity Type:Individual
Prefix:MR
First Name:ELLIOTT
Middle Name:LOUIS
Last Name:KOIVISTO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11785 SW ROBBINS DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7949
Mailing Address - Country:US
Mailing Address - Phone:503-522-2831
Mailing Address - Fax:
Practice Address - Street 1:7145 SW VARNS ST STE 206
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8168
Practice Address - Country:US
Practice Address - Phone:971-405-2584
Practice Address - Fax:800-785-4531
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61377025363LP0808X
OR10005745363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201390875RNOtherOREGON STATE NURSING LICENSE NUMBER
WARN60545376OtherWASHINGTON STATE DEPARTMENT OF HEALTH
WAAP61377025OtherWASHINGTON STATE DEPARTMENT OF HEALTH
OR10005745OtherOREGON STATE NURSING LICENSE