1710205232 NPI number — DR. CLINTON EDWARD QUISENBERRY PH.D.

Table of content: DR. CLINTON EDWARD QUISENBERRY PH.D. (NPI 1710205232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710205232 NPI number — DR. CLINTON EDWARD QUISENBERRY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUISENBERRY
Provider First Name:
CLINTON
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710205232
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7505 SW BEVELAND RD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-747-4646
Provider Business Mailing Address Fax Number:
503-214-8668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7505 SW BEVELAND RD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-8682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-747-4646
Provider Business Practice Location Address Fax Number:
503-214-8668
Provider Enumeration Date:
05/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PY60132400 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 2721 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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