Basic Information
| Provider Information | |||||||||
| NPI: | 1669898268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAINUMA | ||||||||
| FirstName: | KOJI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5033640775 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5033640775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 95001713 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201904695RN | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201905019NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.