Provider Demographics
NPI:1841044534
Name:KEUSINK, IAN WELLES
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:WELLES
Last Name:KEUSINK
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 1:436 S WYNOOSKI ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-3208
Mailing Address - Country:US
Mailing Address - Phone:541-870-4203
Mailing Address - Fax:
Practice Address - Street 1:1308 E 1ST ST STE 3
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2942
Practice Address - Country:US
Practice Address - Phone:503-554-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program