Basic Information
| Provider Information | |||||||||
| NPI: | 1992963011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | WENJUAN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE.210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3653 SE 34TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039884410 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 201405287NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363LF0000X | 17939 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 22959 | 05 | OR | MEDICAID | 096511 | 05 | OR | MEDICAID |