1952393241 NPI number — CHRIS ALBERT PETERSEN PAC

Table of content: CHRIS ALBERT PETERSEN PAC (NPI 1952393241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952393241 NPI number — CHRIS ALBERT PETERSEN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
CHRIS
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952393241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
975 SE SANDY BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97214-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2846
Provider Business Mailing Address Fax Number:
503-963-9505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 OAK ST SE
Provider Second Line Business Practice Location Address:
SUITE 5020
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-3975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-226-6321
Provider Business Practice Location Address Fax Number:
503-227-3422
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  PA00211 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 210476 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8435877 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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