Provider Demographics
NPI:1558315705
Name:MANSOORI, NOOR AGHA (MD)
Entity type:Individual
Prefix:DR
First Name:NOOR
Middle Name:AGHA
Last Name:MANSOORI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5157
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-5157
Mailing Address - Country:US
Mailing Address - Phone:360-667-3056
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:ROOM 2C117
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-487-2500
Practice Address - Fax:360-487-2539
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044849207L00000X
ORMD25411207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8854777Medicare ID - Type Unspecified
I37478Medicare UPIN