Provider Demographics
NPI:1720245418
Name:CHANG, GINA (LAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, DIPLOM
Mailing Address - Street 1:PO BOX 1543
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-1543
Mailing Address - Country:US
Mailing Address - Phone:503-691-7788
Mailing Address - Fax:
Practice Address - Street 1:19365 SW 65TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-691-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 225700000X
ORAC00727171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORAC00727OtherOREGON MEDICAL BOARD