Healthcare Provider Details

I. General information

NPI: 1336903954
Provider Name (Legal Business Name): ALYSSA PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 NE 122ND AVE STE 200
PORTLAND OR
97230-2011
US

IV. Provider business mailing address

1350 NE 122ND AVE
PORTLAND OR
97230-2011
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-7008
  • Fax: 503-408-7045
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA219368
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: