Individual
GRACE LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
930 SW ABBEY ST, NEWPORT, OR 97365-4820
(541) 265-2244
Mailing address
930 SW ABBEY ST, NEWPORT, OR 97365-4820
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA221993
OR
Other
Enumeration date
07/13/2022
Last updated
11/08/2024
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