Provider Demographics
NPI:1023010410
Name:BRADEEN, RESA L (MD)
Entity type:Individual
Prefix:
First Name:RESA
Middle Name:L
Last Name:BRADEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:HYZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 SW MARKET ST STE 1650
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5715
Mailing Address - Country:US
Mailing Address - Phone:503-601-3455
Mailing Address - Fax:
Practice Address - Street 1:9300 SE 91ST AVE STE 200
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3762
Practice Address - Country:US
Practice Address - Phone:503-261-1171
Practice Address - Fax:503-253-5989
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059886Medicaid
F68438Medicare UPIN
OR059886Medicaid