Provider Demographics
NPI:1356169726
Name:REARDON, PAUL MICHAEL JR
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:REARDON
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 1:705 NE 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6217
Mailing Address - Country:US
Mailing Address - Phone:757-818-3796
Mailing Address - Fax:
Practice Address - Street 1:3455 SW VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3076
Practice Address - Country:US
Practice Address - Phone:757-818-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507280RN163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult