Healthcare Provider Details

I. General information

NPI: 1689569642
Provider Name (Legal Business Name): JAIME GWEN FAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2031
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-3860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10055513
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: