Basic Information
| Provider Information | |||||||||
| NPI: | 1649217399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NINO | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 454 WELCH ST | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973811934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731722 | ||||||||
| FaxNumber: | 5038742452 | ||||||||
| Practice Location | |||||||||
| Address1: | 454 WELCH ST | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973811934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731722 | ||||||||
| FaxNumber: | 5038742452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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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 | 2084N0400X | MD26624 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 213201 | 05 | OR | MEDICAID |