Provider Demographics
NPI:1174724157
Name:HARTSHORN, ANNA MALORA (ACNP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MALORA
Last Name:HARTSHORN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-236-0775
Mailing Address - Fax:503-236-0786
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-297-8081
Practice Address - Fax:503-292-6601
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNAPN11462363LF0000X
OR200950124NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174724157Medicaid
OR500613719Medicaid
WA1174724157Medicaid