Basic Information
Provider Information | |||||||||
NPI: | 1508061003 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANNON | ||||||||
FirstName: | SOPHIA | ||||||||
MiddleName: | MARGARETA ROTHBERGER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROTHBERGER | ||||||||
OtherFirstName: | SOPHIA | ||||||||
OtherMiddleName: | MARGARETA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7650 SW BEVELAND RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972238692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036013615 | ||||||||
FaxNumber: | 5036461683 | ||||||||
Practice Location | |||||||||
Address1: | 5050 NE HOYT ST | ||||||||
Address2: | SUITE 230 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972132991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034821800 | ||||||||
FaxNumber: | 5034821805 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | MD171676 | OR | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
ID | Type | State | Issuer | Description | 0239220 | 01 | WA | L&I | OTHER | R185240 | 01 | OR | MEDICARE PTAN | OTHER | 1508061003 | 05 | WA |   | MEDICAID | 500668537 | 05 | OR |   | MEDICAID |