Provider Demographics
NPI:1548404288
Name:PRESTON-KUNTZ, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PRESTON-KUNTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 NE 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200960014CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered