Healthcare Provider Details

I. General information

NPI: 1700582186
Provider Name (Legal Business Name): DANIEL CARMEN FORDIANI III MSN, APRN, A-GNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17200 NW CORRIDOR CT STE 110
BEAVERTON OR
97006-3295
US

IV. Provider business mailing address

17200 NW CORRIDOR CT STE 110
BEAVERTON OR
97006-3295
US

V. Phone/Fax

Practice location:
  • Phone: 503-614-8633
  • Fax: 503-614-8635
Mailing address:
  • Phone: 503-614-8633
  • Fax: 503-614-8635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number10045244
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: