Healthcare Provider Details

I. General information

NPI: 1225150741
Provider Name (Legal Business Name): TERESA ANN MARTISAK RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 E MCANDREWS RD SUITE 170
MEDFORD OR
97504-5589
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-6957
  • Fax: 541-732-7901
Mailing address:
  • Phone: 541-732-6957
  • Fax: 541-732-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number086006602
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: