Healthcare Provider Details

I. General information

NPI: 1124054036
Provider Name (Legal Business Name): STAN W PNIEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALDER ST
SOUTH BEND WA
98586
US

IV. Provider business mailing address

PO BOX 2450
CORVALLIS OR
97339-2450
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3181
  • Fax:
Mailing address:
  • Phone: 541-758-5047
  • Fax: 541-758-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00038267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: