Healthcare Provider Details

I. General information

NPI: 1699874081
Provider Name (Legal Business Name): LISA A FARGO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 SW CEDAR HILLS BLVD #203
BEAVERTON OR
97005-2027
US

IV. Provider business mailing address

13165 SW ESSEX DR
TIGARD OR
97223-5646
US

V. Phone/Fax

Practice location:
  • Phone: 971-645-2257
  • Fax:
Mailing address:
  • Phone: 971-645-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number11230
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: