Provider Demographics
NPI:1801213137
Name:AWTRY, ALISA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:ROSE
Last Name:AWTRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:BERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1000 N PROVIDENCE DR STE 210
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7582
Practice Address - Country:US
Practice Address - Phone:503-537-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138008207Q00000X
ORMD211147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA138008OtherSTATE MEDICAL LICENSE
CAA138008OtherSTATE MEDICAL LICENSE