Healthcare Provider Details

I. General information

NPI: 1174975072
Provider Name (Legal Business Name): KRISTOPHER DAVID BUSKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 SW 13TH AVE
PORTLAND OR
97205-1703
US

IV. Provider business mailing address

1132 SW 13TH AVE
PORTLAND OR
97205-1703
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-3888
  • Fax:
Mailing address:
  • Phone: 503-535-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCPT-0007615
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: