Provider Demographics
NPI:1437422490
Name:BOESHANS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BOESHANS
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 1:1309 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2601
Mailing Address - Country:US
Mailing Address - Phone:503-295-7941
Mailing Address - Fax:503-295-7707
Practice Address - Street 1:1309 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2601
Practice Address - Country:US
Practice Address - Phone:503-295-7941
Practice Address - Fax:503-295-7707
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8864OtherOR PHARMACY LICENSE