Healthcare Provider Details

I. General information

NPI: 1710354337
Provider Name (Legal Business Name): MARC KRISTOPHER OBANDO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA209437
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: