Basic Information
Provider Information
NPI: 1003000753
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DEITLE
FirstName: JAMES
MiddleName: FRANCIS
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 501 N GRAHAM ST
Address2: SUITE #580
City: PORTLAND
State: OR
PostalCode: 972271654
CountryCode: US
TelephoneNumber: 5035280704
FaxNumber: 5035280708
Practice Location
Address1: 501 N GRAHAM ST
Address2: SUITE #580
City: PORTLAND
State: OR
PostalCode: 972271654
CountryCode: US
TelephoneNumber: 5035280704
FaxNumber: 5035280708
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 01/22/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X664AKN Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
363A00000X153509ORY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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