Basic Information
| Provider Information | |||||||||
| NPI: | 1184626970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COURTOX | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032266321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032266321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00260 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500603146 | 05 | OR | MEDICAID |