Basic Information
| Provider Information | |||||||||
| NPI: | 1811981624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLAND | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 NW NORTHRUP ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972091614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032272020 | ||||||||
| FaxNumber: | 5032220614 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 NW NORTHRUP ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972091614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032272020 | ||||||||
| FaxNumber: | 5032220614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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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 | 152W00000X | 4046ATI | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 4046ATI | 01 | OR | OPTOMETRIC LICENSE | OTHER |