Provider Demographics
NPI:1912050360
Name:ANASTASIADIS, SHANNON KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:ANASTASIADIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 NE 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-8009
Mailing Address - Country:US
Mailing Address - Phone:503-735-5230
Mailing Address - Fax:
Practice Address - Street 1:5415 NE 38TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-8009
Practice Address - Country:US
Practice Address - Phone:503-735-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150083NP363LP0200X
OR202114832NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP94485Medicare UPIN
OR116508Medicare ID - Type Unspecified