Provider Demographics
NPI:1023530094
Name:NORTHWEST SURGICAL DEVELOPMENT
Entity type:Organization
Organization Name:NORTHWEST SURGICAL DEVELOPMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-600-9941
Mailing Address - Street 1:65 ENTERPRISE STE 125
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2706
Mailing Address - Country:US
Mailing Address - Phone:949-600-9941
Mailing Address - Fax:949-600-8029
Practice Address - Street 1:17885 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7494
Practice Address - Country:US
Practice Address - Phone:971-246-5291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR167416892086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty