Healthcare Provider Details

I. General information

NPI: 1841208972
Provider Name (Legal Business Name): SANDRA ANN COLLIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST SUITE 200
GRESHAM OR
97030-8316
US

IV. Provider business mailing address

24850 SE STARK ST SUITE 200
GRESHAM OR
97030-8316
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-9444
  • Fax: 503-661-1420
Mailing address:
  • Phone: 503-491-9444
  • Fax: 503-661-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO19348
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier074216
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: