Provider Demographics
NPI:1609972926
Name:NYQUIST, THEODORE THORSTEN (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:THORSTEN
Last Name:NYQUIST
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 1:2163 NW 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9108
Mailing Address - Country:US
Mailing Address - Phone:503-472-4197
Mailing Address - Fax:503-434-2886
Practice Address - Street 1:2163 NW 2ND STREET
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9108
Practice Address - Country:US
Practice Address - Phone:503-472-4197
Practice Address - Fax:503-434-2886
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR056221Medicaid
OR056221Medicaid
F44214Medicare UPIN