Basic Information
| Provider Information | |||||||||
| NPI: | 1366445439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUST | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | EILEEN | ||||||||
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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: | 970358653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037972268 | ||||||||
| FaxNumber: | 5032348227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037234670 | ||||||||
| FaxNumber: | 5032666649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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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 | 200150096 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 275246 | 05 | OR | MEDICAID |