Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | MD15031 | OR |
NPI | 1720176332 |
---|---|
Provider Name | Dr. Beverly Ann De La Bruere |
First Address | Damascus, OR 97089-8764 |
Second Address | Damascus, OR 97089-8764 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 02/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110403 | (05) | OR |
C92493 | (02) | OR |