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General NPI Number Information
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NPI Number | 1265883151
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Entity Type | Individual
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Provider Name | NATHAN HANTKE PH.D.
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Gender | Male
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Dates
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Enumeration Date | 06/22/2016
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Last Update Date | 12/27/2018
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Provider Practice Location Address
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Address Line | 3303 SW BOND AVE STE 8
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 503-494-7772
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Fax | 503-418-3283
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Provider Business Mailing Address
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Address Line | 3303 SW BOND AVE STE 8
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City | PORTLAND
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State | OR
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Zip | 97239-4501
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Country | US
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Telephone | 503-494-7772
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Fax | 503-418-3283
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 2970
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 28285
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License Number State | CA
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