Individual
MICAH DESHAZO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
14600 NW CORNELL RD, PORTLAND, OR 97229-5442
(503) 555-5555
Mailing address
14600 NW CORNELL RD, PORTLAND, OR 97229-5442
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
OR
Other
Enumeration date
10/08/2019
Last updated
10/08/2019
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