Provider Demographics
NPI:1548235393
Name:PEDERSEN, ANDREW DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:DALE
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 655
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-488-2400
Practice Address - Fax:503-231-0121
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60381043207Y00000X
ORMD19567207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080320Medicaid
WA8448896Medicaid
ORG28112Medicare UPIN
WA8448896Medicaid
WA8921275Medicare PIN