Healthcare Provider Details

I. General information

NPI: 1750130290
Provider Name (Legal Business Name): DEVAN ROBERT LEAGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2024
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 13TH ST
BAKER CITY OR
97814-1340
US

IV. Provider business mailing address

3425 13TH ST
BAKER CITY OR
97814-1340
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-7400
  • Fax: 541-523-4927
Mailing address:
  • Phone: 541-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number114706
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number24-CRM-3267
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: