Individual
ROBERT WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
7201 N INTERSTATE AVE, PORTLAND, OR 97217-5523
(503) 240-4088
Mailing address
7201 N INTERSTATE AVE, PORTLAND, OR 97217-5523
(503) 240-4088
Taxonomy
Speciality
Code
Description
License number
State
136A00000X
Registered Dietetic Technician
Primary
525079
IL
Other
Enumeration date
07/22/2014
Last updated
07/22/2014
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