Provider Demographics
NPI:1699978650
Name:SWANSON, MARTA JOY (RD)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:JOY
Last Name:SWANSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-413-4926
Mailing Address - Fax:
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4926
Practice Address - Fax:503-413-2212
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001802133V00000X
OR857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8444242Medicaid