Basic Information
| Provider Information | |||||||||
| NPI: | 1376720052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | SHEVYLL ARVIE | ||||||||
| MiddleName: | SIONG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4365 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 24988 STARK. ST., LEGACY MEDICAL GROUP MOUNT HOOD | ||||||||
| Address2: | SUITE 220 MEDICAL OFFICE BLDG 3 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525834791 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 50459 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD186467 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.