1689630410 NPI number — MS. INGRID LARGE EDSTROM BSN CFNP MED

Table of content: MS. INGRID LARGE EDSTROM BSN CFNP MED (NPI 1689630410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689630410 NPI number — MS. INGRID LARGE EDSTROM BSN CFNP MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDSTROM
Provider First Name:
INGRID
Provider Middle Name:
LARGE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BSN CFNP MED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PADBERG
Provider Other First Name:
INGRID
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689630410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 HODSON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97404-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-302-2977
Provider Business Mailing Address Fax Number:
541-302-6565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 GOODPASTURE ISLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-2109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-302-2977
Provider Business Practice Location Address Fax Number:
541-302-6565
Provider Enumeration Date:
04/21/2006

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: 363LF0000X , with the licence number:  1113222 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 200550045NPPP , 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: 269858 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200550045NPPP . This is a "OR FNP#" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP2194 . This is a "BCBS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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