Provider Demographics
NPI:1730668021
Name:HALBASCH, GARY LEE (LPN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:HALBASCH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2876
Mailing Address - Country:US
Mailing Address - Phone:503-239-8101
Mailing Address - Fax:503-408-5201
Practice Address - Street 1:722 NE 162ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5760
Practice Address - Country:US
Practice Address - Phone:503-239-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201709227164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse