Provider Demographics
NPI:1427029537
Name:HURSEY, PHYLLIS DESHUN (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:DESHUN
Last Name:HURSEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13215 SE MILL PLAIN BLVD STE C8
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6999
Mailing Address - Country:US
Mailing Address - Phone:503-269-2409
Mailing Address - Fax:503-389-1161
Practice Address - Street 1:1206 SE 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3601
Practice Address - Country:US
Practice Address - Phone:503-389-1166
Practice Address - Fax:503-389-1161
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26240207Q00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD26240OtherLICENCE
ORMD26240OtherLICENCE