Organization
WESTSIDE PEDIATRIC CLINIC PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CONNIE LYNN DISTEFANO (ADMINISTRATOR)
(503) 297-1025
Entity
Organization
Contact information
Practice address
9555 SW BARNES RD, SUITE 270, PORTLAND, OR 97225
(503) 297-1025
(503) 297-1043
Mailing address
9555 SW BARNES RD, SUITE 270, PORTLAND, OR 97225
(503) 297-1025
(503) 297-1043
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
150220
—
OR
Enumeration date
05/09/2007
Last updated
04/11/2008
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