Provider Demographics
NPI:1750575239
Name:KUSIN, SHANA G (MD)
Entity type:Individual
Prefix:DR
First Name:SHANA
Middle Name:G
Last Name:KUSIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE CB 550
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-4885
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:MAIL CODE EM-CDRW
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-818-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154163207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine