Healthcare Provider Details

I. General information

NPI: 1831269265
Provider Name (Legal Business Name): ANDREW TISTADT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21810 WILLAMETTE DR STE 200
WEST LINN OR
97068-3287
US

IV. Provider business mailing address

21810 WILLAMETTE DR STE 200
WEST LINN OR
97068-3287
US

V. Phone/Fax

Practice location:
  • Phone: 503-994-4353
  • Fax: 503-722-5100
Mailing address:
  • Phone: 503-994-4353
  • Fax: 503-722-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01174
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: