Provider Demographics
NPI:1740470897
Name:RISSLER, REBECCA A (NNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:RISSLER
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:TEVENAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:NICU
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-413-1864
Mailing Address - Fax:503-413-2589
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:NICU
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-1864
Practice Address - Fax:503-413-2589
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650047NP363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218660Medicaid
WA9658006Medicaid