1164646485 NPI number — DR. SHARON W SU M.D.

Table of content: DR. SHARON W SU M.D. (NPI 1164646485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164646485 NPI number — DR. SHARON W SU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SU
Provider First Name:
SHARON
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164646485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 N GRAHAM ST STE 355
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97227-2005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-413-3926
Provider Business Mailing Address Fax Number:
503-413-3927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N GRAHAM ST
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-413-3090
Provider Business Practice Location Address Fax Number:
503-413-3948
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0210X , with the licence number:  MD12760 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A91776 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: MD12760 . This is a "LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: MD157897 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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