Provider Demographics
NPI:1578927414
Name:FIVECOAT, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:FIVECOAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1938
Mailing Address - Country:US
Mailing Address - Phone:503-772-4335
Mailing Address - Fax:503-772-4337
Practice Address - Street 1:8935 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1938
Practice Address - Country:US
Practice Address - Phone:503-772-4335
Practice Address - Fax:503-772-4337
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK102193163W00000X, 363LF0000X
OR201806384RN363L00000X
WARN60908911363L00000X
WAAP60909960363L00000X
OR201808083NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily