Basic Information
| Provider Information | |||||||||
| NPI: | 1134252851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIST | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 SW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032210161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9250 SW HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972236721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032930161 | ||||||||
| FaxNumber: | 5032979357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6604923-8905 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | MD28274 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.