Basic Information
| Provider Information | |||||||||
| NPI: | 1912923152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NONWEILER | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 NW NAITO PKWY | ||||||||
| Address2: | STE 185 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972092535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035257690 | ||||||||
| FaxNumber: | 5035257652 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE NEFF RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | 5413222286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | MD19775 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 077537 | 05 | OR | MEDICAID |