Facts
- Status
- A
- Credential
- OTR
- Type
- Individual
- Enumeration date
- 2006-10-11
- Last updated
- 2008-04-17
Specialties
Licenses
- License OR
- 4705
Location
- Practice location
- 158 SHARON DR
- City
- PHOENIX OR
- Postal code
- 975355713
- Phone
- 541-608-0464
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.