Provider Demographics
NPI:1376205278
Name:CANIZALEZ, MARSHALL ALBERT (AUD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:ALBERT
Last Name:CANIZALEZ
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:24076 SE STARK ST STE 230
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3385
Practice Address - Country:US
Practice Address - Phone:503-488-2600
Practice Address - Fax:503-465-5468
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001852231H00000X
237600000X
OR31054231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500813168Medicaid