Healthcare Provider Details

I. General information

NPI: 1750399283
Provider Name (Legal Business Name): GUANG FAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK ROAD, MAIL CODE L471
PORTLAND OR
97239
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberMD23079
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD23079
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: