Provider Demographics
NPI:1952749087
Name:PHAN, ALEXANDER (RN)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 NE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2011
Mailing Address - Country:US
Mailing Address - Phone:503-408-7008
Mailing Address - Fax:503-408-7045
Practice Address - Street 1:1350 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230
Practice Address - Country:US
Practice Address - Phone:503-408-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2019-04-14
Deactivation Date:2019-01-13
Deactivation Code:
Reactivation Date:2019-01-18
Provider Licenses
StateLicense IDTaxonomies
OR201900297NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274147Medicaid