Provider Demographics
NPI:1588765523
Name:PORTLAND VA MEDICAL CENTER
Entity type:Organization
Organization Name:PORTLAND VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GERIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:KAPUALANI
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:GNP
Authorized Official - Phone:503-237-0153
Mailing Address - Street 1:21950 S UPPER HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97004-8810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR060018996N3ANP/GNP314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility