Basic Information
| Provider Information | |||||||||
| NPI: | 1164877023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLASI | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17550 PROVOST ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970345199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035133350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2016 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | DO200035 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.