Provider Demographics
NPI:1598772311
Name:HARTMAN, IAN MARQUES (PA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MARQUES
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:PA
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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-962-1020
Practice Address - Fax:503-962-1021
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01148363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500603584Medicaid
OR500603584Medicaid
ORQ74026Medicare UPIN
OR135576Medicare PIN