Provider Demographics
NPI:1134626831
Name:ACOSTA, LILIANA
Entity type:Individual
Prefix:
First Name:LILIANA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 SE 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2396
Mailing Address - Country:US
Mailing Address - Phone:509-225-3396
Mailing Address - Fax:
Practice Address - Street 1:6200 SE KING RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2891
Practice Address - Country:US
Practice Address - Phone:503-546-6377
Practice Address - Fax:503-545-9397
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1275695934Medicaid