Provider Demographics
NPI:1558792945
Name:HOSEA, RILEY YOUNG
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:YOUNG
Last Name:HOSEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 NE WASCO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1738
Mailing Address - Country:US
Mailing Address - Phone:760-207-6051
Mailing Address - Fax:
Practice Address - Street 1:3944 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1163
Practice Address - Country:US
Practice Address - Phone:503-517-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20006171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor