Healthcare Provider Details

I. General information

NPI: 1487653796
Provider Name (Legal Business Name): SUSAN I VANGORDER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK ROAD OHSU
PORTLAND OR
97239-3098
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK ROAD OHSU
PORTLAND OR
97239-3098
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8014
  • Fax: 503-494-2251
Mailing address:
  • Phone: 503-494-8014
  • Fax: 503-494-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0001131932
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0024165997
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: