Provider Demographics
NPI:1568464261
Name:EVANS, BRADLEY H (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:H
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24900 SE STARK ST STE 109
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3381
Mailing Address - Country:US
Mailing Address - Phone:503-413-7162
Mailing Address - Fax:503-674-4140
Practice Address - Street 1:24900 SE STARK ST STE 109
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3381
Practice Address - Country:US
Practice Address - Phone:503-413-7162
Practice Address - Fax:503-674-4140
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043084207RC0000X
ORMD17468207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029939Medicaid
WA8129918Medicaid
OR157723Medicare PIN
OR06WCBBPBMedicare ID - Type Unspecified
WA8129918Medicaid