MEDICARE: CHRIS ALBERT PETERSEN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA00211	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952393241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRIS ALBERT PETERSEN PAC

Provider Business Mailing Address
First Line	:	975 SE SANDY BLVD
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97214-1308
Country	:	US
Telephone Number	:	503-963-2846
Fax Number	:	503-963-9505

Provider Business Practice Location Address
First Line	:	875 OAK ST SE
Second Line	:	SUITE 5020
City	:	SALEM
State	:	OR
Zip	:	97301-3975
Country	:	US
Telephone Number	:	503-226-6321
Fax Number	:	503-227-3422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	08/19/2009

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Directions to “ CHRIS ALBERT PETERSEN PAC” Practice Location

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