Provider Demographics
NPI:1942593876
Name:SHANGO, MARYANN M (MD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:M
Last Name:SHANGO
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 1:12123 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8514
Mailing Address - Country:US
Mailing Address - Phone:971-708-7600
Mailing Address - Fax:971-371-5230
Practice Address - Street 1:12123 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8514
Practice Address - Country:US
Practice Address - Phone:971-708-7600
Practice Address - Fax:971-371-5230
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098522390200000X
WAMD60739968207RH0003X
ORMD198359207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program