Healthcare Provider Details

I. General information

NPI: 1164646485
Provider Name (Legal Business Name): SHARON W SU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N GRAHAM ST SUITE 315
PORTLAND OR
97227
US

IV. Provider business mailing address

501 N GRAHAM ST STE 355
PORTLAND OR
97227-2005
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-3090
  • Fax: 503-413-3948
Mailing address:
  • Phone: 503-413-3926
  • Fax: 503-413-3927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD12760
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: