Basic Information
| Provider Information | |||||||||
| NPI: | 1750399283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | GUANG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK ROAD, MAIL CODE L471 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948276 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 207ZH0000X | MD23079 | OR | Y | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | MD23079 | OR | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 228925 | 05 | OR | MEDICAID |