Provider Demographics
NPI:1275041436
Name:BRUDERLIN, FRED MCLANE JR
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:MCLANE
Last Name:BRUDERLIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ATWATER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2115
Mailing Address - Country:US
Mailing Address - Phone:503-704-6658
Mailing Address - Fax:
Practice Address - Street 1:5211 NE GLISAN ST BLDG C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3052
Practice Address - Country:US
Practice Address - Phone:503-704-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker