Basic Information
| Provider Information | |||||||||
| NPI: | 1831368711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUSAK | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 S MACADAM AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972396102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712025500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5100 S MACADAM AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972396102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712025500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-49579 | HI | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN140381 | LA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP07265 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN-1283 | HI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 612484 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201501099NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500696121 | 05 | OR | MEDICAID |