Healthcare Provider Details

I. General information

NPI: 1427304864
Provider Name (Legal Business Name): MARTIN G DEGROOT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17200 NW CORRIDOR CT SUITE 105
BEAVERTON OR
97006-3295
US

IV. Provider business mailing address

17200 NW CORRIDOR CT SUITE 105
BEAVERTON OR
97006-3295
US

V. Phone/Fax

Practice location:
  • Phone: 503-614-8400
  • Fax:
Mailing address:
  • Phone: 503-614-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: