Provider Demographics
NPI:1760654479
Name:PIONEER FAMILY MEDICINE PC
Entity type:Organization
Organization Name:PIONEER FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:A
Authorized Official - Last Name:EWBANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-266-9000
Mailing Address - Street 1:452 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3532
Mailing Address - Country:US
Mailing Address - Phone:503-266-9000
Mailing Address - Fax:503-266-9200
Practice Address - Street 1:452 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3532
Practice Address - Country:US
Practice Address - Phone:503-266-9000
Practice Address - Fax:503-266-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133934Medicaid
OR133934Medicaid
OR131969Medicare PIN