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NPI Code Detail

MEDICARE: SUSAN A BLASI D.O.

MEDICARE: SUSAN A BLASI D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2207Q00000XFamily Medicine PhysicianDO200035OR

General Provider Information

NPI Number : 1164877023
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN A BLASI D.O.
Provider Business Mailing Address
First Line : PO BOX 3158
Second Line :
City : PORTLAND
State : OR
Zip : 97208-3158
Country : US
Telephone Number : 503-215-6494
Fax Number :
Provider Business Practice Location Address
First Line : 17550 PROVOST ST STE 201
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97034-5199
Country : US
Telephone Number : 503-513-3350
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2016
Last Update Date : 01/29/2021

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Directions to “ SUSAN A BLASI D.O.” Practice Location

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