Provider Demographics
NPI:1609641901
Name:PETERSON, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 NE MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3048
Mailing Address - Country:US
Mailing Address - Phone:503-334-5721
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10006366163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse