Healthcare Provider Details

I. General information

NPI: 1255802849
Provider Name (Legal Business Name): SANDRA S HWANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2018
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST STE 220
GRESHAM OR
97030-8324
US

IV. Provider business mailing address

1650 NW NAITO PKWY STE 185
PORTLAND OR
97209-2535
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1580
  • Fax: 503-674-1581
Mailing address:
  • Phone: 971-983-5260
  • Fax: 971-983-5326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA191291
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: