Provider Demographics
NPI:1437573185
Name:PORTLAND PLASTIC SURGERY GROUP, LLC
Entity Type:Organization
Organization Name:PORTLAND PLASTIC SURGERY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BILLI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:NOWKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-928-3001
Mailing Address - Street 1:1200 NW NAITO PKWY STE 310
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2829
Mailing Address - Country:US
Mailing Address - Phone:503-292-9200
Mailing Address - Fax:503-292-9205
Practice Address - Street 1:1200 NW NAITO PKWY STE 310
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2829
Practice Address - Country:US
Practice Address - Phone:503-292-9200
Practice Address - Fax:503-292-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty