Provider Demographics
NPI:1376720052
Name:TAN, SHEVYLL ARVIE SIONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEVYLL ARVIE
Middle Name:SIONG
Last Name:TAN
Suffix:
Gender:F
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:PO BOX 4365
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4365
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:24988 STARK. ST., LEGACY MEDICAL GROUP MOUNT HOOD
Practice Address - Street 2:SUITE 220 MEDICAL OFFICE BLDG 3
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:952-583-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50459207R00000X
ORMD186467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine