Provider Demographics
NPI:1023865052
Name:VON BURG, ERIN (LE)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:VON BURG
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2318
Mailing Address - Country:US
Mailing Address - Phone:503-459-6438
Mailing Address - Fax:
Practice Address - Street 1:2646 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2318
Practice Address - Country:US
Practice Address - Phone:503-459-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E-10193842174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist