Provider Demographics
NPI:1770094682
Name:LOHSTROH, SANDRA EUGENIA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:EUGENIA
Last Name:LOHSTROH
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 1:13927 SE TENINO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-6633
Mailing Address - Country:US
Mailing Address - Phone:503-956-7850
Mailing Address - Fax:
Practice Address - Street 1:178 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4152
Practice Address - Country:US
Practice Address - Phone:503-416-4547
Practice Address - Fax:503-416-4553
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201808979NP363LF0000X
WAAP60896892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500764500Medicaid