Provider Demographics
NPI:1851384937
Name:YANASE, LISA RIETZ (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RIETZ
Last Name:YANASE
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-215-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT365452084N0400X
AK1084392084N0400X
WAMD602168932084N0400X
ORMD260242084N0400X
CAC1449012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01238739OtherRR MEDICARE (PH&S)-PMG
OR213502Medicaid
OR213502Medicaid
ORR171950Medicare PIN
ORR192511Medicare PIN
ORR167636Medicare PIN
ORP01238739OtherRR MEDICARE (PH&S)-PMG
CACB269674Medicare PIN