Provider Demographics
NPI:1275129793
Name:BALTHAZARD, BILL-BERN
Entity Type:Individual
Prefix:
First Name:BILL-BERN
Middle Name:
Last Name:BALTHAZARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 NE BROADWAY ST APT 240
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3462
Mailing Address - Country:US
Mailing Address - Phone:484-274-1910
Mailing Address - Fax:
Practice Address - Street 1:1555 N TOMAHAWK ISLAND DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7912
Practice Address - Country:US
Practice Address - Phone:503-205-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61112817183700000X
ORCPT-0012541183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician