Provider Demographics
NPI:1689630410
Name:EDSTROM, INGRID LARGE (BSN CFNP MED)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:LARGE
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:BSN CFNP MED
Other - Prefix:
Other - First Name:INGRID
Other - Middle Name:
Other - Last Name:PADBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1102 HODSON LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2944
Mailing Address - Country:US
Mailing Address - Phone:541-302-2977
Mailing Address - Fax:541-302-6565
Practice Address - Street 1:315 GOODPASTURE ISLAND RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2109
Practice Address - Country:US
Practice Address - Phone:541-302-2977
Practice Address - Fax:541-302-6565
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1113222363LF0000X
OR200550045NPPP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269858Medicaid
200550045NPPPOtherOR FNP#
ORNP2194OtherBCBS
ORS98121Medicare UPIN
ORR132760Medicare PIN