Provider Demographics
NPI:1104673425
Name:LEESON, AUSTIN (DC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:LEESON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 SW NORTH DAKOTA ST STE 180
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-0802
Mailing Address - Country:US
Mailing Address - Phone:503-716-8281
Mailing Address - Fax:
Practice Address - Street 1:12700 SW NORTH DAKOTA ST STE 180
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-0802
Practice Address - Country:US
Practice Address - Phone:503-716-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor