Provider Demographics
NPI:1609419225
Name:IDRIS, FARDOWSA SHARIFF (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:SHARIFF
Last Name:IDRIS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 SW 65TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9712
Mailing Address - Country:US
Mailing Address - Phone:503-828-1150
Mailing Address - Fax:503-828-1160
Practice Address - Street 1:19255 SW 65TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9712
Practice Address - Country:US
Practice Address - Phone:503-828-1150
Practice Address - Fax:503-828-1160
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty