Healthcare Provider Details

I. General information

NPI: 1740515097
Provider Name (Legal Business Name): SKYE ANTHONY NEHS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST STE 300
GRESHAM OR
97030-8325
US

IV. Provider business mailing address

24988 SE STARK ST STE 300
GRESHAM OR
97030-8325
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-7162
  • Fax: 503-674-4140
Mailing address:
  • Phone: 503-413-7162
  • Fax: 503-674-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1683
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA174474
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: