Provider Demographics
NPI:1730484312
Name:ANDERSEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST STE 138
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2955
Mailing Address - Country:US
Mailing Address - Phone:503-238-1062
Mailing Address - Fax:503-233-1588
Practice Address - Street 1:5050 NE HOYT ST STE 138
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2955
Practice Address - Country:US
Practice Address - Phone:503-238-1062
Practice Address - Fax:503-233-1588
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA160150363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R167362Medicare PIN