Provider Demographics
NPI:1114035656
Name:BERTALOT, MARCIA (ANP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BERTALOT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:
Other - Last Name:GOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:3633 NW 163RD TER
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7245
Mailing Address - Country:US
Mailing Address - Phone:503-645-1517
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-499-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004275363LA2200X
OR096006178N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health