Provider Demographics
NPI:1700016698
Name:ELDRED, JEREMIAH LEE (APRN)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:LEE
Last Name:ELDRED
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:360-608-9017
Mailing Address - Fax:
Practice Address - Street 1:1350 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2011
Practice Address - Country:US
Practice Address - Phone:503-408-7008
Practice Address - Fax:503-408-7045
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-25
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN39486363LF0000X
OR201150192NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily