Provider Demographics
NPI:1831273077
Name:KIESSLING, PETER JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JONATHAN
Last Name:KIESSLING
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 1:4235 WEST BAY RD.
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5523
Mailing Address - Country:US
Mailing Address - Phone:503-635-9980
Mailing Address - Fax:
Practice Address - Street 1:LOCUM TENENS (MULTIPLE LOCATIONS)
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5523
Practice Address - Country:US
Practice Address - Phone:503-635-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 10083207ZP0102X
WAMD 10973207ZP0102X
CAG25292207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C93042Medicare UPIN