Provider Demographics
NPI:1023010410
Name:BRADEEN, RESA L (MD)
Entity Type:Individual
Prefix:
First Name:RESA
Middle Name:L
Last Name:BRADEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:HYZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1960 NW 167TH PL
Mailing Address - Street 2:STE 200
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4803
Mailing Address - Country:US
Mailing Address - Phone:503-531-2594
Mailing Address - Fax:503-466-1399
Practice Address - Street 1:10535 NE GLISAN ST
Practice Address - Street 2:STE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4077
Practice Address - Country:US
Practice Address - Phone:503-261-1171
Practice Address - Fax:503-253-5989
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059886Medicaid
F68438Medicare UPIN
OR059886Medicaid