Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1073609871 |
---|---|
Provider Name | Jonathan Ray Gregory |
First Address | Portland, OR 97211 |
Second Address | Beaverton, OR 97005-3460 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2006 |
Last Update Date | 08/07/2007 |