Provider Demographics
NPI:1740461912
Name:EVANS, SHANE ROBERT (BS/ QMHA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ROBERT
Last Name:EVANS
Suffix:
Gender:M
Credentials:BS/ QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 MADISON ST. A
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1929
Mailing Address - Country:US
Mailing Address - Phone:503-256-3040
Mailing Address - Fax:503-256-9601
Practice Address - Street 1:1500 N.E. IRVING ST.
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-233-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator