Provider Demographics
NPI:1770696221
Name:PROBST, KEVIN NORMAN (NP)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:NORMAN
Last Name:PROBST
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5820 BIRD SONG WAY
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1581
Mailing Address - Country:US
Mailing Address - Phone:503-341-4039
Mailing Address - Fax:
Practice Address - Street 1:3550 N. INTERSTATE AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1097
Practice Address - Country:US
Practice Address - Phone:503-331-6493
Practice Address - Fax:503-249-5528
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005823363LA2200X
OR000038096N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health