Provider Demographics
NPI:1952393241
Name:PETERSEN, CHRIS ALBERT (PAC)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:ALBERT
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-963-2846
Mailing Address - Fax:503-963-9505
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 5020
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-226-6321
Practice Address - Fax:503-227-3422
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00211363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210476Medicaid
WA8435877Medicaid
WA8435877Medicaid
OR210476Medicaid
OR116065Medicare ID - Type UnspecifiedPORTLAND