Provider Demographics
NPI:1417286204
Name:SATYA, SHOBA (LICAC)
Entity Type:Individual
Prefix:
First Name:SHOBA
Middle Name:
Last Name:SATYA
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 SW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4609
Mailing Address - Country:US
Mailing Address - Phone:360-977-0020
Mailing Address - Fax:
Practice Address - Street 1:4916 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2547
Practice Address - Country:US
Practice Address - Phone:360-977-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234403171100000X
WAAC 60264876171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist