Provider Demographics
NPI:1720306160
Name:GRAWCOCK, MICHAEL RYAN (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:GRAWCOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4318 SW DICKINSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7456
Mailing Address - Country:US
Mailing Address - Phone:503-806-6671
Mailing Address - Fax:
Practice Address - Street 1:4318 SW DICKINSON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-7456
Practice Address - Country:US
Practice Address - Phone:503-806-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist