Basic Information
| Provider Information | |||||||||
| NPI: | 1174724157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTSHORN | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | MALORA | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 SE SANDY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032360775 | ||||||||
| FaxNumber: | 5032360786 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 SW BARNES RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032978081 | ||||||||
| FaxNumber: | 5032926601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN11462 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2100X | 200950124NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1174724157 | 05 | WA | MEDICAID | 500613719 | 05 | OR | MEDICAID |