Provider Demographics
NPI:1265883151
Name:HANTKE, NATHAN (PHD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:HANTKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-7772
Mailing Address - Fax:503-418-3283
Practice Address - Street 1:3303 SW BOND AVE STE 8
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-7772
Practice Address - Fax:503-418-3283
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2970103G00000X
CA28285103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist