Basic Information
| Provider Information | |||||||||
| NPI: | 1558311688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALLA | ||||||||
| FirstName: | SUVARNA | ||||||||
| MiddleName: | REDDY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 SW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032210161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6640 SW REDWOOD LN | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036207358 | ||||||||
| FaxNumber: | 5039242260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | MD21274 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | MD21274 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 136352 | 05 | OR | MEDICAID |