Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | PA173635 | OR |
NPI | 1033437298 |
---|---|
Provider Name | Jennifer Kay Bane |
First Address | Portland, OR 97205-2714 |
Second Address | Portland, OR 97205-2732 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2010 |
Last Update Date | 13/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2010430 | (05) | WA |
P25953 | (02) |