Provider Demographics
NPI:1316618044
Name:THANASOUK, NIK
Entity type:Individual
Prefix:
First Name:NIK
Middle Name:
Last Name:THANASOUK
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 1:13636 SE CALLAHAN RD
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-6022
Mailing Address - Country:US
Mailing Address - Phone:503-317-1531
Mailing Address - Fax:
Practice Address - Street 1:13636 SE CALLAHAN RD
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-6022
Practice Address - Country:US
Practice Address - Phone:503-317-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor