Provider Demographics
NPI:1205958576
Name:PETERSON, VANESSA L (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 SE MAIN ST STE 11
Mailing Address - Street 2:PORTLAND LUNG CLINIC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2937
Mailing Address - Country:US
Mailing Address - Phone:503-253-2248
Mailing Address - Fax:
Practice Address - Street 1:10201 SE MAIN ST
Practice Address - Street 2:PORTLAND LUNG CLINIC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2937
Practice Address - Country:US
Practice Address - Phone:503-253-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2012-10-12
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-07-24
Provider Licenses
StateLicense IDTaxonomies
ORMD151179207RS0012X
WAMD60237646207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine