Provider Demographics
NPI:1760236566
Name:WEBER, EVAN JONATHON (PMHNP)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JONATHON
Last Name:WEBER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13228 SE BROOKLYN CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3035
Mailing Address - Country:US
Mailing Address - Phone:917-583-5128
Mailing Address - Fax:
Practice Address - Street 1:13228 SE BROOKLYN CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3035
Practice Address - Country:US
Practice Address - Phone:917-583-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10024561363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health