Provider Demographics
NPI:1558364489
Name:FUNG, CAROLINE MAY-SAN (PA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MAY-SAN
Last Name:FUNG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 SW BARNES RD
Mailing Address - Street 2:STE 150
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6663
Mailing Address - Country:US
Mailing Address - Phone:503-297-7403
Mailing Address - Fax:503-384-9908
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:STE 150
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6663
Practice Address - Country:US
Practice Address - Phone:503-297-7403
Practice Address - Fax:503-384-9908
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00763363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604574Medicaid
WA1013208Medicaid
OR500604574Medicaid
ORP00950Medicare UPIN
ORR111466Medicare PIN