Healthcare Provider Details

I. General information

NPI: 1932522166
Provider Name (Legal Business Name): DEFFO MEBRAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 NW LINNEMAN AVE
GRESHAM OR
97030-6248
US

IV. Provider business mailing address

135 NW LINNEMAN AVE
GRESHAM OR
97030-6248
US

V. Phone/Fax

Practice location:
  • Phone: 971-678-0443
  • Fax: 503-328-9705
Mailing address:
  • Phone: 971-678-0443
  • Fax: 503-328-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200740288
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: