Provider Demographics
NPI:1164608717
Name:WHISNANT, BRAD HAROLD (LAC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:HAROLD
Last Name:WHISNANT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11160 SW WAVERLY PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4456
Mailing Address - Country:US
Mailing Address - Phone:503-750-6238
Mailing Address - Fax:
Practice Address - Street 1:10490 SW EASTRIDGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5030
Practice Address - Country:US
Practice Address - Phone:503-750-6238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01151171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist