MEDICARE: ANDREW TISTADT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA01174	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831269265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW TISTADT PA-C

Provider Business Mailing Address
First Line	:	21810 WILLAMETTE DR STE 200
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-3287
Country	:	US
Telephone Number	:	503-994-4353
Fax Number	:	503-722-5100

Provider Business Practice Location Address
First Line	:	21810 WILLAMETTE DR STE 200
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-3287
Country	:	US
Telephone Number	:	503-994-4353
Fax Number	:	503-722-5100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	03/12/2026

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Directions to “ ANDREW TISTADT PA-C” Practice Location

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