Individual
NATHAN FASOLD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5029 NE KILLINGSWORTH ST, PORTLAND, OR 97218
(503) 402-8117
Mailing address
PO BOX 8459, PORTLAND, OR 97207-8459
(503) 238-0769
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
Primary
200842345RN
OR
372600000X
Adult Companion
—
—
Other
Enumeration date
04/01/2009
Last updated
11/15/2010
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