Provider Demographics
NPI:1134151822
Name:WARREN, RICHARD T (ANP)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:WARREN
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:T
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:6350 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4720
Practice Address - Country:US
Practice Address - Phone:503-215-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1134151822363LA2200X
OR084054476N3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ61106Medicare UPIN