MEDICARE: DR. CHARISSE NISCE SIAPNO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	099202	OH
2	207R00000X	Internal Medicine Physician	MD171548	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720219520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARISSE NISCE SIAPNO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:	541-535-1274
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 FERN VALLEY RD STE A
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-9100
Country	:	US
Telephone Number	:	541-535-1274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2009
Last Update Date	:	11/05/2015

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