Provider Demographics
NPI:1689211013
Name:PETERSON, MERITT ALEENA (PA-C)
Entity Type:Individual
Prefix:
First Name:MERITT
Middle Name:ALEENA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:2222 NW LOVEJOY ST STE 622
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5104
Practice Address - Country:US
Practice Address - Phone:503-229-8455
Practice Address - Fax:503-299-7028
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA196473363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2149182Medicaid
OR500775809Medicaid