Providence Health & Services - Oregon

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

PROVIDENCE HEALTH & SERVICES - OREGON

Practice address

4004 Kruse Way PL Ste 300
Lake Oswego, OR 97035-2479

Phone

(503) 216-1500

NPI assigned

Sep 25, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Donald Wayne Anderson Jr.

Title

Assistant Secreatry for Enrollment

Phone

(425) 358-9786

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 2

• PROVIDENCE MEDICAL GROUP Doing business as
• PROVIDENCE MEDICAL GROUP MERCANTILE Doing business as

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Megan J. Barton, APRN-BC, FNP

  • Family Nurse Practitioner
  • Hood River, OR
  • NPI 1265666549
  NPD
• Laura Elizabeth Bennetts, MD

  • Internal Medicine Physician
  • Portland, OR
  • NPI 1760006118
  NPD
• Hayley M Cusick, P.A.-C

  • Physician Assistant
  • Portland, OR
  • NPI 1780131532
  NPD
• Jessica E Decker, DO

  • Neurology Physician
  • Portland, OR
  • NPI 1649835422
  NPD
• Jun Ma, ACNP

  • Nurse Practitioner
  • Portland, OR
  • NPI 1417266354
  NPD
• Bridget Meade-Sentosun, PA-C

  • Physician Assistant
  • Portland, OR
  • NPI 1639786411
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159142400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751587200000",
    "number": "1205937273",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001 - 4180",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104180",
            "telephone_number": "503-215-6494",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4004 KRUSE WAY PL STE 300",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970352479",
            "telephone_number": "503-216-1500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-25",
        "last_updated": "2025-07-04",
        "certification_date": "2025-07-04",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECREATRY FOR ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "241291",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP MERCANTILE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Premere Rehab LLC
• Premere Rehab LLC
• Kathleen Elizabeth Preuss, LCSW
• Pro-Tech Sports Medicine, Inc.
• Proactive Health Resources, LLC
• Providence Health & Services - Oregon
• Providence Health & Services Oregon
• Amber Nicole Pruitt, JD
• Robin Prusse, RN,BSN
• Psych NW, PC

• All providers in Lake Oswego, OR
• Family Medicine Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 4, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.