Provider Demographics
NPI:1568861367
Name:EVENS, KYRA
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:EVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:2701 NW VAUGHN ST STE 155
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5348
Practice Address - Country:US
Practice Address - Phone:503-227-3479
Practice Address - Fax:503-223-4838
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675848Medicaid
OR0329717OtherWA L&I
OR0329717OtherWA L&I
ORR177286Medicare PIN