Basic Information
| Provider Information | |||||||||
| NPI: | 1275585069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAWTHORNE | ||||||||
| FirstName: | WENDY | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CENTERPOINTE DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970358660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037972254 | ||||||||
| FaxNumber: | 5039140335 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 SW HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036441171 | ||||||||
| FaxNumber: | 5036437443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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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 | 363LA2200X | 090000324N3 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 276415 | 05 | OR | MEDICAID | 500011385 | 01 | RR MEDICARE | OTHER | MH0287246 | 01 | DEA | OTHER |