Provider Demographics
NPI:1548566227
Name:DEVASTO, PHILIP A (DC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:DEVASTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4817 SW HUMPHREY PARK CRST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2333
Mailing Address - Country:US
Mailing Address - Phone:617-365-1527
Mailing Address - Fax:
Practice Address - Street 1:16679 BOONES FERRY RD STE 105
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4378
Practice Address - Country:US
Practice Address - Phone:503-635-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor