Provider Demographics
NPI:1811073216
Name:RETTLER, CRISTIN ANGELA (PA)
Entity type:Individual
Prefix:
First Name:CRISTIN
Middle Name:ANGELA
Last Name:RETTLER
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 1:1040 NW 22ND AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-227-5050
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:STE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-227-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10952363A00000X
ORPA00903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR235275Medicaid
OR115727Medicare PIN