Healthcare Provider Details

I. General information

NPI: 1679027874
Provider Name (Legal Business Name): EPHRAIM SHIN-TIAN TANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST STE 6N60
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

4805 NE GLISAN ST STE 6N60
PORTLAND OR
97213-2933
US

V. Phone/Fax

Practice location:
  • Phone: 503-281-0561
  • Fax:
Mailing address:
  • Phone: 503-281-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD184038
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD184038
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: