Provider Demographics
NPI:1164072286
Name:VAN, THIEN-HUONG THERESA (PA)
Entity type:Individual
Prefix:
First Name:THIEN-HUONG
Middle Name:THERESA
Last Name:VAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:4816 NW BETHANY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9254
Mailing Address - Country:US
Mailing Address - Phone:888-227-3312
Mailing Address - Fax:971-282-0100
Practice Address - Street 1:4816 NW BETHANY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9254
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:971-282-0100
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA202904363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2278171Medicaid
OR500791146Medicaid