Provider Demographics
NPI:1659867042
Name:NISEWANDER, STEPHEN JAE
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JAE
Last Name:NISEWANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 THRONE DR APT 304
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-7752
Mailing Address - Country:US
Mailing Address - Phone:541-206-4707
Mailing Address - Fax:
Practice Address - Street 1:735 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-7507
Practice Address - Country:US
Practice Address - Phone:541-895-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant