Healthcare Provider Details

I. General information

NPI: 1912923152
Provider Name (Legal Business Name): BLAKE A NONWEILER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 200
BEND OR
97701-4281
US

IV. Provider business mailing address

1650 NW NAITO PKWY STE 185
PORTLAND OR
97209-2535
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3344
  • Fax: 541-322-2286
Mailing address:
  • Phone: 503-525-7690
  • Fax: 503-525-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD19775
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: