Provider Demographics
NPI:1053616441
Name:CALLAWAY, GINA MARIE (LMT 17789)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:LMT 17789
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT 17789
Mailing Address - Street 1:11501 SW PACIFIC HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8649
Mailing Address - Country:US
Mailing Address - Phone:503-862-7787
Mailing Address - Fax:
Practice Address - Street 1:11501 SW PACIFIC HWY STE 100
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8649
Practice Address - Country:US
Practice Address - Phone:503-862-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT 17789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist