Provider Demographics
NPI:1699032466
Name:PAGE, ANDREW (OR LMT #15989)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:OR LMT #15989
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 E BURNSIDE ST STE 217
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1231
Mailing Address - Country:US
Mailing Address - Phone:500-344-6086
Mailing Address - Fax:
Practice Address - Street 1:811 E BURNSIDE ST STE 217
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1231
Practice Address - Country:US
Practice Address - Phone:500-344-6086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist