Basic Information
Provider Information | |||||||||
NPI: | 1316178189 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AMAVISCA | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | ALBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19875 SW 65TH AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | TUALATIN | ||||||||
State: | OR | ||||||||
PostalCode: | 970628353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034133900 | ||||||||
FaxNumber: | 5034133710 | ||||||||
Practice Location | |||||||||
Address1: | 19875 SW 65TH AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | TUALATIN | ||||||||
State: | OR | ||||||||
PostalCode: | 97062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036927785 | ||||||||
FaxNumber: | 5036922520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2009 | ||||||||
LastUpdateDate: | 08/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | NJ | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | MD156341 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1407812365 | 01 | OR | NBMC GROUP NPI # | OTHER | 161133 | 01 | OR | NBMC GROUP MEDICAID | OTHER | 930635514 | 01 | OR | NBMC GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | NBMC GROUP MEDICARE # | OTHER | 500672860 | 05 | OR |   | MEDICAID |