Healthcare Provider Details

I. General information

NPI: 1063565018
Provider Name (Legal Business Name): ANDREA GAYLE WHETSELL RT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

1986 NE VISTA AVE
GRESHAM OR
97030-4158
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 503-666-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number415190
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: