Basic Information
| Provider Information | |||||||||
| NPI: | 1558322909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYONATOR | ||||||||
| FirstName: | EDEM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92900 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032572500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10123 SE MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032572500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD26162 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD26162 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 858464008 | 01 | OR | BCBS-SPRINGFIELD | OTHER | 858463010 | 01 | OR | BCBS-MEDFORD | OTHER | P00276736 | 01 | OR | RR MEDICARE | OTHER | 026826 | 05 | OR | MEDICAID | 838334011 | 01 | OR | BCBS-ROSEBURG | OTHER |