Healthcare Provider Details

I. General information

NPI: 1548799174
Provider Name (Legal Business Name): AMANDA NGOUAJIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST STE 607
PORTLAND OR
97210-5104
US

IV. Provider business mailing address

2222 NW LOVEJOY ST STE 607
PORTLAND OR
97210-5104
US

V. Phone/Fax

Practice location:
  • Phone: 503-222-3638
  • Fax: 503-223-5139
Mailing address:
  • Phone: 503-222-3638
  • Fax: 503-223-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberR-10996
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberR-10996
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR-10996
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberR-10996
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberR-10996
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberR-10996
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberR-10996
License Number StateIA
# 8
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberR-10996
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: