Basic Information
| Provider Information | |||||||||
| NPI: | 1801898358 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NISKANEN | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 DAGGETT AVE. | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418826311 | ||||||||
| FaxNumber: | 5418826311 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 DAGGETT AVE. | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418826311 | ||||||||
| FaxNumber: | 5418826311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD18831 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9782 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006600 | 05 | OR | MEDICAID | BN4082056 | 01 | FEDERAL DEA # | OTHER | POO100692 | 01 | RAILROAD MEDICARE | OTHER | 0108854YPNH02 | 01 | NH | ANTHEM BC/BS | OTHER | 30009720 | 05 | NH | MEDICAID | 3059734PNH02 | 01 | NH | CIGNA | OTHER | 5830418 | 01 | AETNA | OTHER | 8782 | 01 | NH | STATE LICENSE # | OTHER |