Basic Information
| Provider Information | |||||||||
| NPI: | 1700978046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANG | ||||||||
| FirstName: | N | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 NW 22ND AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032297353 | ||||||||
| FaxNumber: | 5032297255 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 NW VAUGHN ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032274050 | ||||||||
| FaxNumber: | 5034777673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD20041 | OR | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 081661 | 05 | OR | MEDICAID |