Provider Demographics
NPI:1487653796
Name:VANGORDER, SUSAN I (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:I
Last Name:VANGORDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK ROAD
Mailing Address - Street 2:OHSU
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-494-8014
Mailing Address - Fax:503-494-2251
Practice Address - Street 1:3181 SW SAM JACKSON PARK ROAD
Practice Address - Street 2:OHSU
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-8014
Practice Address - Fax:503-494-2251
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001131932207L00000X
VA0024165997207L00000X
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
014066A50Medicare ID - Type Unspecified