Basic Information
| Provider Information | |||||||||
| NPI: | 1568720563 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OREVI | ||||||||
| FirstName: | DIKLAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980035947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61250 SE COOMBS PL | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417065930 | ||||||||
| FaxNumber: | 5417065931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 22099 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA158116 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.