Provider Demographics
NPI:1316017585
Name:BUNKER, THERESA (FNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BUNKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NE 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3934
Mailing Address - Country:US
Mailing Address - Phone:503-460-0405
Mailing Address - Fax:503-460-0434
Practice Address - Street 1:1410 NE 106TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3934
Practice Address - Country:US
Practice Address - Phone:503-460-0405
Practice Address - Fax:503-460-0434
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096006685N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210222Medicaid
ORS76269Medicare UPIN
OR118602Medicare ID - Type Unspecified