Provider Demographics
NPI:1275585069
Name:HAWTHORNE, WENDY (ANP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CENTERPOINTE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8660
Mailing Address - Country:US
Mailing Address - Phone:503-797-2254
Mailing Address - Fax:503-914-0335
Practice Address - Street 1:4510 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-644-1171
Practice Address - Fax:503-643-7443
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090000324N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276415Medicaid
500011385OtherRR MEDICARE
MH0287246OtherDEA
ORS43670Medicare UPIN
OR276415Medicaid