Provider Demographics
NPI:1356005482
Name:DAGOSTINO, ANDREW P
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:P
Last Name:DAGOSTINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 SE 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4454
Mailing Address - Country:US
Mailing Address - Phone:408-472-5976
Mailing Address - Fax:
Practice Address - Street 1:1900 E FULTON ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1806
Practice Address - Country:US
Practice Address - Phone:408-472-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98115133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty