Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0402X | Child Neurologist | MD21910 | OR |
NPI | 1356358287 |
---|---|
Provider Name | Stephen Arthur Back |
First Address | Lake Oswego, OR 97035-1014 |
Second Address | Portland, OR 97239-3011 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
134084 | (05) | OR |
H00564 | (02) |