MEDICARE: ALISE NICHOLE ROBERSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	NOT YET ISSUED	OR
2	152W00000X	Optometrist	3671ATI	OR

General Provider Information

NPI Number	:	1871956136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISE NICHOLE ROBERSON O.D.

Provider Business Mailing Address
First Line	:	3010 SW 10TH AVE APT 52
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3059
Country	:	US
Telephone Number	:	949-303-8969
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1106
Country	:	US
Telephone Number	:	503-249-3429
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2016
Last Update Date	:	02/04/2022

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