Healthcare Provider Details

I. General information

NPI: 1326306721
Provider Name (Legal Business Name): ANDREA KLUNDER PETERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N GANTENBEIN AVE STE 2225
PORTLAND OR
97227-1623
US

IV. Provider business mailing address

PO BOX 4399
PORTLAND OR
97208-4399
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-4505
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD181125
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD181125
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: