Individual
SHANE AUSTIN SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
7405 SE 84TH AVE, PORTLAND, OR 97266-5840
(503) 771-1645
Mailing address
12248 SE MARKET ST, PORTLAND, OR 97233-1235
(503) 995-4778
Taxonomy
Speciality
Code
Description
License number
State
372600000X
Adult Companion
Primary
—
—
Other
Enumeration date
11/11/2014
Last updated
11/11/2014
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