Provider Demographics
NPI:1801898358
Name:NISKANEN, GRANT (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:NISKANEN
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 1:2865 DAGGETT AVE.
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-882-6311
Mailing Address - Fax:541-882-6311
Practice Address - Street 1:2865 DAGGETT AVE.
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-882-6311
Practice Address - Fax:541-882-6311
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18831207Q00000X
NH9782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006600Medicaid
POO100692OtherRAILROAD MEDICARE
NH0108854YPNH02OtherANTHEM BC/BS
NH30009720Medicaid
NH3059734PNH02OtherCIGNA
5830418OtherAETNA
NH8782OtherSTATE LICENSE #
NH8782OtherSTATE LICENSE #
NH0108854YPNH02OtherANTHEM BC/BS