Provider Demographics
NPI:1619636388
Name:RANABHAT, JASUDHA (NP)
Entity Type:Individual
Prefix:
First Name:JASUDHA
Middle Name:
Last Name:RANABHAT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16442 SW 132ND TER
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3080
Mailing Address - Country:US
Mailing Address - Phone:503-473-6975
Mailing Address - Fax:
Practice Address - Street 1:12045 SE STANLEY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2938
Practice Address - Country:US
Practice Address - Phone:503-659-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202112438NP-PP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology