Healthcare Provider Details

I. General information

NPI: 1992797039
Provider Name (Legal Business Name): CYNTHIA ANN BOHAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 NE 47TH AVE SUITE 200
PORTLAND OR
97213-2236
US

IV. Provider business mailing address

975 SE SANDY BLVD SUITE 200
PORTLAND OR
97214-1308
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-2300
  • Fax: 503-215-2283
Mailing address:
  • Phone: 503-963-2846
  • Fax: 503-963-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA01008
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: