Basic Information
| Provider Information | |||||||||
| NPI: | 1205429008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELDE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTESON | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 22009 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972692009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035587372 | ||||||||
| FaxNumber: | 5033445140 | ||||||||
| Practice Location | |||||||||
| Address1: | 2318 PORTLAND RD, STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035381341 | ||||||||
| FaxNumber: | 5035381343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2021 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | ATI4628 | OR | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.