Healthcare Provider Details

I. General information

NPI: 1689496218
Provider Name (Legal Business Name): ANDREY ZHOLNEROVICH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 HAWTHORNE AVE SE STE 110
SALEM OR
97301-5378
US

IV. Provider business mailing address

610 HAWTHORNE AVE SE STE 110
SALEM OR
97301-5378
US

V. Phone/Fax

Practice location:
  • Phone: 503-814-4440
  • Fax: 503-814-4444
Mailing address:
  • Phone: 503-814-4440
  • Fax: 503-814-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10034392
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: