Provider Demographics
NPI:1366445439
Name:BLUST, DIANNE EILEEN (ANP)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:EILEEN
Last Name:BLUST
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:97035-8653
Mailing Address - Country:US
Mailing Address - Phone:503-797-2268
Mailing Address - Fax:503-234-8227
Practice Address - Street 1:1185 S ELM ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3935
Practice Address - Country:US
Practice Address - Phone:503-723-4670
Practice Address - Fax:503-266-6649
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150096363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275246Medicaid
OR118451Medicare ID - Type Unspecified
ORP44250Medicare UPIN