Provider Demographics
NPI:1053302265
Name:AVONDSTONDT, LAURENT E O (NP)
Entity Type:Individual
Prefix:
First Name:LAURENT
Middle Name:E O
Last Name:AVONDSTONDT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 482 BOX 1600
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-9998
Mailing Address - Country:US
Mailing Address - Phone:315-643-7977
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:503-731-1035
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350144NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR9625955Medicaid
OR9625955Medicaid
117993Medicare ID - Type Unspecified