Healthcare Provider Details

I. General information

NPI: 1205463312
Provider Name (Legal Business Name): ANDREA LEIGH HUXTABLE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 NW VAUGHN ST STE 150
PORTLAND OR
97210-5379
US

IV. Provider business mailing address

847 NE 19TH AVE STE 300
PORTLAND OR
97232-2686
US

V. Phone/Fax

Practice location:
  • Phone: 503-229-8455
  • Fax: 503-229-7028
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA202788
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: