Basic Information
| Provider Information | |||||||||
| NPI: | 1952393241 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | CHRIS | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 SE SANDY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632846 | ||||||||
| FaxNumber: | 5039639505 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 OAK ST SE | ||||||||
| Address2: | SUITE 5020 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032266321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA00211 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 210476 | 05 | OR | MEDICAID | 8435877 | 05 | WA | MEDICAID |