Healthcare Provider Details

I. General information

NPI: 1154010429
Provider Name (Legal Business Name): PREMIER ANESTHESIA OF OREGON PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N PROVIDENCE DR
NEWBERG OR
97132-7485
US

IV. Provider business mailing address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

V. Phone/Fax

Practice location:
  • Phone: 678-690-7816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDY WALKER
Title or Position: VP FINANCE
Credential:
Phone: 678-690-7812