Healthcare Provider Details

I. General information

NPI: 1891126538
Provider Name (Legal Business Name): SYDMARIE BISENIUS N.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 150
GRESHAM OR
97030-8318
US

IV. Provider business mailing address

24850 SE STARK ST STE 150
GRESHAM OR
97030-8318
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-0714
  • Fax:
Mailing address:
  • Phone: 503-491-0714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberND2029
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: