Provider Demographics
NPI:1255329967
Name:FERNSTROM, BRUCE (PA)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:FERNSTROM
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:501 N GRAHAM ST STE 420
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2006
Practice Address - Country:US
Practice Address - Phone:503-288-7303
Practice Address - Fax:503-288-3806
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00805363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500600862Medicaid
P60448Medicare UPIN
OR181315Medicare PIN
OR500600862Medicaid