Provider Demographics
NPI:1811504814
Name:WHEELER, JEREMY (LMT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WHEELER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1748 NW FAIRVIEW DR # A
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3842
Mailing Address - Country:US
Mailing Address - Phone:503-492-3910
Mailing Address - Fax:
Practice Address - Street 1:1748 NW FAIRVIEW DR # A
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3842
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10440246Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10440OtherLMT