Basic Information
| Provider Information | |||||||||
| NPI: | 1811073216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RETTLER | ||||||||
| FirstName: | CRISTIN | ||||||||
| MiddleName: | ANGELA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | STE 500 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032275050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | STE 500 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032275050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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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 | 363A00000X | PA00903 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 235275 | 05 | OR | MEDICAID |