Provider Demographics
NPI:1962945295
Name:LUNDIN, AUDREY (AGPCNP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LUNDIN
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:AUDREY ROSE
Other - Middle Name:DE LUNA CANTOR
Other - Last Name:LUNDIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGPCNP
Mailing Address - Street 1:5100 S MACADAM AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3827
Mailing Address - Country:US
Mailing Address - Phone:971-202-5500
Mailing Address - Fax:971-202-5555
Practice Address - Street 1:5100 S MACADAM AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3827
Practice Address - Country:US
Practice Address - Phone:971-202-5500
Practice Address - Fax:971-202-5555
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201609120NP-PP363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner