Provider Demographics
NPI:1790132017
Name:XIAO, GEOFFREY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:
Last Name:XIAO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:800-272-6512
Practice Address - Street 1:15895 SW 72ND AVE STE 250
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7966
Practice Address - Country:US
Practice Address - Phone:503-624-5630
Practice Address - Fax:503-624-9149
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA178428363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2079317Medicaid
OR500717752Medicaid