Provider Demographics
NPI:1104252097
Name:BODIAN, SARAH ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:BODIAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-292-3577
Mailing Address - Fax:503-292-3947
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6663
Practice Address - Country:US
Practice Address - Phone:503-292-3577
Practice Address - Fax:503-292-3947
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201405790NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675844Medicaid
ORR178941OtherMEDICARE PTAN