Healthcare Provider Details

I. General information

NPI: 1285674499
Provider Name (Legal Business Name): SANDRA CAROL BROEREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17055 RUBEN LN
SANDY OR
97055-9276
US

IV. Provider business mailing address

17055 RUBEN LN
SANDY OR
97055-9276
US

V. Phone/Fax

Practice location:
  • Phone: 503-668-8002
  • Fax: 503-668-5246
Mailing address:
  • Phone: 503-668-8002
  • Fax: 503-668-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26866
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD157517
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: