Basic Information
| Provider Information | |||||||||
| NPI: | 1326306721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | KLUNDER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4399 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 N GANTENBEIN AVE STE 2225 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034134505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 208000000X | MD181125 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207SG0201X | MD181125 | OR | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
No ID Information.