Basic Information
| Provider Information | |||||||||
| NPI: | 1841956182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JOHN-BRIAN | ||||||||
| MiddleName: | WYCKOFF | ||||||||
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| Credential: | CRM, PSS, LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3872 COHO CIR | ||||||||
| Address2: | |||||||||
| City: | FOREST GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971163096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033130070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 971 SW WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971235651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036405297 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2021 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | THW000105572 | OR | Y |
No ID Information.