Provider Demographics
NPI:1407559230
Name:CANCHOLA, YAIRA
Entity Type:Individual
Prefix:
First Name:YAIRA
Middle Name:
Last Name:CANCHOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YAIRA
Other - Middle Name:
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6200 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2891
Mailing Address - Country:US
Mailing Address - Phone:971-335-7798
Mailing Address - Fax:
Practice Address - Street 1:6200 SE KING RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2891
Practice Address - Country:US
Practice Address - Phone:971-335-7798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2890933172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker