Provider Demographics
NPI:1386932887
Name:KERTH, SHANNON R (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:KERTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 NE DEKUM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3102 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-6638
Practice Address - Country:US
Practice Address - Phone:503-777-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist