Provider Demographics
NPI:1407844525
Name:GOLDBERG, DEIDRE (FNP)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:
Last Name:GOLDBERG
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: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:541-732-7850
Mailing Address - Fax:541-732-7851
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:STE 300
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-7850
Practice Address - Fax:541-732-7851
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR82022347363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009238Medicaid
OR009238Medicaid
OR009238Medicaid