Provider Demographics
NPI:1912729898
Name:WITTEN, SHAY FOREST
Entity type:Individual
Prefix:
First Name:SHAY
Middle Name:FOREST
Last Name:WITTEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8803 N TYNDALL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7029
Mailing Address - Country:US
Mailing Address - Phone:541-805-9282
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST STE 606
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5104
Practice Address - Country:US
Practice Address - Phone:503-413-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E10249501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist