Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 272343 | OR |
NPI | 1093804148 |
---|---|
Provider Name | Dr. Randy Lee Hewitt |
First Address | Portland, OR 97214-1649 |
Second Address | Portland, OR 97214-1649 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |