Individual
BRYAN DALE PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3181 SW SAM JACKSON PARK RD, PORTLAND, OR 97239-3011
(503) 494-7660
Mailing address
14930 NW GILLIHAN RD, PORTLAND, OR 97231-1519
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
Primary
MD15285
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
028105
—
OR
Enumeration date
08/01/2006
Last updated
07/08/2007
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