Provider Demographics
NPI:1073267464
Name:NISHI, MIWA ANDRINA (LMT)
Entity Type:Individual
Prefix:MS
First Name:MIWA
Middle Name:ANDRINA
Last Name:NISHI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MIWA
Other - Middle Name:ANDRINA
Other - Last Name:MCREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9850 SE HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3735
Mailing Address - Country:US
Mailing Address - Phone:503-260-0288
Mailing Address - Fax:
Practice Address - Street 1:1117 SE 122ND AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1160
Practice Address - Country:US
Practice Address - Phone:503-946-8633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist