Provider Demographics
NPI:1790888907
Name:CRIST, AUDREY A (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:A
Last Name:CRIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ANN
Other - Last Name:CRIST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:325 NE 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5003
Mailing Address - Country:US
Mailing Address - Phone:503-756-0552
Mailing Address - Fax:
Practice Address - Street 1:19500 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5757
Practice Address - Country:US
Practice Address - Phone:503-669-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine