Basic Information
Provider Information
NPI: 1003002379
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHRESTHA
FirstName: SALONA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 3158
Address2:  
City: PORTLAND
State: OR
PostalCode: 972083158
CountryCode: US
TelephoneNumber: 5032156494
FaxNumber:  
Practice Location
Address1: 4805 NE GLISAN ST
Address2:  
City: PORTLAND
State: OR
PostalCode: 972132933
CountryCode: US
TelephoneNumber: 5032152392
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/20/2007
LastUpdateDate: 12/06/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XMD160505ORY Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000XMD00048484WAN Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
838968605WA MEDICAID
P0046866201WARR MEDICAREOTHER
P004866201WARR MEDICAREOTHER
849723205WA MEDICAID


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