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General NPI Number Information
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NPI Number | 1255329967
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Entity Type | Individual
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Provider Name | BRUCE FERNSTROM PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/07/2005
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 501 N GRAHAM ST STE 420
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City | PORTLAND
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State | OR
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Zip | 97227-2006
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Country | US
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Telephone | 503-288-7303
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Fax | 503-288-3806
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Provider Business Mailing Address
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Address Line | 541 NE 20TH AVE STE 225
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City | PORTLAND
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State | OR
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Zip | 97232-2895
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Country | US
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Telephone | 503-963-2801
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Fax | 503-963-2825
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA00805
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA00805
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License Number State | OR
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