Basic Information
| Provider Information | |||||||||
| NPI: | 1376558882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMMONS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038551620 | ||||||||
| FaxNumber: | 5038403299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 PROVIDENCE DR | ||||||||
| Address2: | STE 340 | ||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971327485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035382698 | ||||||||
| FaxNumber: | 5035549328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD14746 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 216028 | 05 | OR | MEDICAID | R157974 | 01 | OR | MEDICARE PTAN | OTHER |