Basic Information
| Provider Information | |||||||||
| NPI: | 1386263077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENDA | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | JOANNE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4399 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034134340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WESTERN UNIVERSITY OF HEALTH SCIENCES COMP-NORTHWEST | ||||||||
| Address2: | 200 MULLINS DR. | ||||||||
| City: | LEBANON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412590235 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1386263077 | 05 | OR | MEDICAID |