MEDICARE: PATH SOLARIS LLC

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
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609453992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH SOLARIS LLC

Provider Business Mailing Address
First Line	:	1842 NW 25TH AVE STE D
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-2568
Country	:	US
Telephone Number	:	415-254-4445
Fax Number	:

Provider Business Practice Location Address
First Line	:	1842 NW 25TH AVE STE D
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-2568
Country	:	US
Telephone Number	:	415-254-4445
Fax Number	:

Authorized Official
Title or Position	:	DR
Name	:	MICHELLE YAN
Credential	:	DSOM, LA.,
Telephone Number	:	415-254-4445

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	03/24/2021

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Directions to “PATH SOLARIS LLC ” Practice Location

Language	Start Address	Practice Location

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