Provider Demographics
NPI:1265493399
Name:RIVARD-DIBENEDETTO, SUSAN E (PA C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:RIVARD-DIBENEDETTO
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003271363AM0700X
ORPA151129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8377012Medicaid
P27594Medicare UPIN
WA8377012Medicaid