Basic Information
| Provider Information | |||||||||
| NPI: | 1265794135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAGANO | ||||||||
| FirstName: | ANGIE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD STE 367 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036503110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9775 SE SUNNYSIDE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02004315 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO184246 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 71489-21 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201089980 | 05 | IN | MEDICAID |