# EVERGREEN PEDIATRIC CLINIC PS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144343773
- **Authorized official:** TERI BRYANT (OFFICE MANAGER)
- **Authorized official phone:** (360) 892-1635

## Contact information

- **Practice address:** 505 NE 87TH AVE, STE 120, VANCOUVER, WA 98664-1989
- **Practice address phone:** (360) 892-1635
- **Practice address fax:** (360) 892-3146
- **Mailing address:** 505 NE 87TH AVE, STE 120, VANCOUVER, WA 98664-1989
- **Mailing address phone:** (360) 892-1635
- **Mailing address fax:** (360) 892-3146

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | 601 115 723 | WA | Yes |

## Other

- **Enumeration date:** 04/09/2007
- **Last updated:** 02/21/2020