Healthcare Provider Details

I. General information

NPI: 1427306232
Provider Name (Legal Business Name): PETER BORDELON PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 NW CRAFTSMAN DR
BEND OR
97703-5517
US

IV. Provider business mailing address

3159 NW CRAFTSMAN DR
BEND OR
97703-5517
US

V. Phone/Fax

Practice location:
  • Phone: 720-743-2255
  • Fax: 720-743-2155
Mailing address:
  • Phone: 720-249-5211
  • Fax: 720-743-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR189202
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0996417-NP
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10005773
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: