Provider Demographics
NPI:1164410874
Name:STANDAGE, BLAYNE A (MD)
Entity Type:Individual
Prefix:
First Name:BLAYNE
Middle Name:A
Last Name:STANDAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2900
Mailing Address - Country:US
Mailing Address - Phone:503-226-4325
Mailing Address - Fax:503-227-5024
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-226-4325
Practice Address - Fax:503-227-5024
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12970208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12970OtherSTATE LICENSE
OR161513Medicaid
OR00WCGJKCMedicare ID - Type Unspecified
MD12970OtherSTATE LICENSE