Provider Demographics
NPI:1609453992
Name:PATH SOLARIS LLC
Entity Type:Organization
Organization Name:PATH SOLARIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:YAN
Authorized Official - Suffix:
Authorized Official - Credentials:DSOM, LA,
Authorized Official - Phone:415-254-4445
Mailing Address - Street 1:1842 NW 25TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2568
Mailing Address - Country:US
Mailing Address - Phone:415-254-4445
Mailing Address - Fax:
Practice Address - Street 1:1842 NW 25TH AVE STE D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2568
Practice Address - Country:US
Practice Address - Phone:415-254-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1164043022Medicaid