Provider Demographics
NPI:1346854759
Name:ELSOME, AMANDA K (AGACNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:ELSOME
Suffix:
Gender:F
Credentials:AGACNP
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-5545
Mailing Address - Fax:
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:541-732-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2103363LA2100X
OR10003863363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care