Provider Demographics
NPI:1124054036
Name:PNIEWSKI, STAN W (MD)
Entity type:Individual
Prefix:
First Name:STAN
Middle Name:W
Last Name:PNIEWSKI
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:PO BOX 2450
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2450
Mailing Address - Country:US
Mailing Address - Phone:541-758-5047
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:800 ALDER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586
Practice Address - Country:US
Practice Address - Phone:360-642-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000382672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1111152Medicaid
WAGAB16236Medicare PIN
WAA78715Medicare UPIN