Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | MD153961 | OR |
NPI | 1114153194 |
---|---|
Provider Name | Dr. Martin Athelstan Baggenstos |
First Address | Portland, OR 97232-2684 |
Second Address | Portland, OR 97225-6625 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2009 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1114153194 | (05) | WA |
500635997 | (05) | OR |