Basic Information
| Provider Information | |||||||||
| NPI: | 1528155280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWTON-KLUCEVEK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9250 SW HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032930161 | ||||||||
| FaxNumber: | 5032214451 | ||||||||
| Practice Location | |||||||||
| Address1: | 9450 SW BARNES RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929560 | ||||||||
| FaxNumber: | 5032929510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO21207 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0021207 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 287850 | 05 | OR | MEDICAID |