Provider Demographics
NPI:1720219520
Name:SIAPNO, CHARISSE NISCE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:NISCE
Last Name:SIAPNO
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-535-1274
Mailing Address - Fax:
Practice Address - Street 1:205 FERN VALLEY RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9100
Practice Address - Country:US
Practice Address - Phone:541-535-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH099202207R00000X
ORMD171548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500689112Medicaid
ORR183037Medicare PIN