Provider Demographics
NPI:1689202228
Name:STANCO, KAHLEY MARIEL (DO)
Entity type:Individual
Prefix:
First Name:KAHLEY
Middle Name:MARIEL
Last Name:STANCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2964
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-721-7957
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-721-7957
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO221199207RG0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine