Provider Demographics
NPI:1326041526
Name:QUILICI, NATE D (MD)
Entity Type:Individual
Prefix:DR
First Name:NATE
Middle Name:D
Last Name:QUILICI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 SW BARNES RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6608
Mailing Address - Country:US
Mailing Address - Phone:503-292-9108
Mailing Address - Fax:503-292-0346
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2181
Practice Address - Fax:503-216-4850
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7798174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232678Medicaid
OR232678Medicaid
OR0000WCGDSEMedicare ID - Type Unspecified