38D1095013 CLIA NUMBER - PROVIDENCE MEDICAL GROUP WILSONVILLE

Laboratory Demographics

  • CLIA Code: 38D1095013
  • Facility Name: PROVIDENCE MEDICAL GROUP WILSONVILLE
  • Facility Address: 29345 SW TOWN CENTER LOOP EAST SUITE110
    WILSONVILLE, OR
    ZIP 97070
  • Facility Phone: 503 582-2100
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: JAY A SHAH MD
  • NPI Number: 1245489087
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 38D1095013
LAB Type Physician Office
Facility Name PROVIDENCE MEDICAL GROUP WILSONVILLE
Street 29345 SW TOWN CENTER LOOP EAST SUITE110
City WILSONVILLE
State OR
ZIP 97070
Phone 503 582-2100
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/29/2025
Certificate Expiration Date 1/28/2027
Facility Type Physician Office
Lab Director JAY A SHAH MD

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This page was last updated on: 9/29/2025