Individual
LAN BAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
9135 SW BARNES RD STE 763, PORTLAND, OR 97225-6777
(503) 216-8250
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD189134
OR
390200000X
Student in an Organized Health Care Education/Training Program
PG173562
OR
Other
Enumeration date
06/12/2015
Last updated
10/06/2020
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