Healthcare Provider Details

I. General information

NPI: 1144337221
Provider Name (Legal Business Name): LUANNE NILSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

IV. Provider business mailing address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-7565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD15125
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00025684
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: