Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | MD10115 | OR |
Y | 111NI0900X | Internist | MD10115 | OR |
N | 207RA0401X | Internist - Addiction Medicine | MD10115 | OR |
NPI | 1528067972 |
---|---|
Provider Name | Andris Antoniskis |
First Address | Portland, OR 97208-3158 |
Second Address | Portland, OR 97213-3055 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2005 |
Last Update Date | 07/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
220376 | (05) | OR |
500626738 | (05) | OR |
C94249 | (02) |