Provider Demographics
NPI:1790066751
Name:NASRALLAH, WESAM A (MD,)
Entity Type:Individual
Prefix:
First Name:WESAM
Middle Name:A
Last Name:NASRALLAH
Suffix:
Gender:M
Credentials:MD,
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 RD
Mailing Address - Street 2:MAIL CODE OP31
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-6404
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:MAIL CODE OP31
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORFE175723207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery