Provider Demographics
NPI:1205976990
Name:BROWN, WYATT JAMES (CPED)
Entity type:Individual
Prefix:MR
First Name:WYATT
Middle Name:JAMES
Last Name:BROWN
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16679 BOONES FERRY RD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4368
Mailing Address - Country:US
Mailing Address - Phone:503-699-1911
Mailing Address - Fax:503-699-1912
Practice Address - Street 1:16679 BOONES FERRY RD
Practice Address - Street 2:STE 215
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4365
Practice Address - Country:US
Practice Address - Phone:503-699-1911
Practice Address - Fax:503-699-1912
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0876099-5174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist