Provider Demographics
NPI:1306638036
Name:MESIANO, DANIEL FONTILLAS
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:FONTILLAS
Last Name:MESIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12340 SW CENTER ST APT 44
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-5409
Mailing Address - Country:US
Mailing Address - Phone:503-440-1329
Mailing Address - Fax:
Practice Address - Street 1:12340 SW CENTER ST APT 44
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-5409
Practice Address - Country:US
Practice Address - Phone:503-440-1329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA883006172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver