Provider Demographics
NPI:1902950645
Name:SISCO, DANIEL JAMES (ND)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:SISCO
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1816
Mailing Address - Country:US
Mailing Address - Phone:503-282-9222
Mailing Address - Fax:503-282-8116
Practice Address - Street 1:3351 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1816
Practice Address - Country:US
Practice Address - Phone:503-282-9222
Practice Address - Fax:503-282-8116
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000536261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR27805-1Medicaid