Provider Demographics
NPI:1831269265
Name:TISTADT, ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TISTADT
Suffix:
Gender:M
Credentials:PA-C
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 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD STE 304
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01174363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500622688Medicaid