Healthcare Provider Details

I. General information

NPI: 1023010410
Provider Name (Legal Business Name): RESA L BRADEEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA L HYZER MD

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 SE 91ST AVE STE 200
HAPPY VALLEY OR
97086-3762
US

IV. Provider business mailing address

200 SW MARKET ST STE 1650
PORTLAND OR
97201-5715
US

V. Phone/Fax

Practice location:
  • Phone: 503-261-1171
  • Fax: 503-253-5989
Mailing address:
  • Phone: 503-601-3455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD17410
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: