Provider Demographics
NPI:1124662887
Name:EYSMONT, YEVGENIY (ND, LMT)
Entity type:Individual
Prefix:
First Name:YEVGENIY
Middle Name:
Last Name:EYSMONT
Suffix:
Gender:M
Credentials:ND, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11667 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2264
Mailing Address - Country:US
Mailing Address - Phone:971-420-2102
Mailing Address - Fax:
Practice Address - Street 1:11667 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2264
Practice Address - Country:US
Practice Address - Phone:971-420-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23604225700000X
OR4306175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist