Healthcare Provider Details

I. General information

NPI: 1750068920
Provider Name (Legal Business Name): PAKE R. NIELSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7318 N LEAVITT AVE
PORTLAND OR
97203-4840
US

IV. Provider business mailing address

8532 N IVANHOE ST STE 201
PORTLAND OR
97203-4827
US

V. Phone/Fax

Practice location:
  • Phone: 503-567-5880
  • Fax: 866-629-1294
Mailing address:
  • Phone: 503-567-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27782
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: