Provider Demographics
NPI:1952459190
Name:AVERSANO, A P (DO)
Entity Type:Individual
Prefix:DR
First Name:A
Middle Name:P
Last Name:AVERSANO
Suffix:
Gender:M
Credentials:DO
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 2053
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0632
Mailing Address - Country:US
Mailing Address - Phone:509-837-4366
Mailing Address - Fax:509-837-4344
Practice Address - Street 1:9200 SE 91ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-6756
Practice Address - Country:US
Practice Address - Phone:509-837-4366
Practice Address - Fax:509-837-4344
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO101932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232405Medicaid
E05487Medicare UPIN
0000WCGNLMedicare ID - Type Unspecified