Provider Demographics
NPI:1174992044
Name:KNEISLY, ANTAR
Entity type:Individual
Prefix:
First Name:ANTAR
Middle Name:
Last Name:KNEISLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-515-8504
Mailing Address - Fax:
Practice Address - Street 1:2222 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4966
Practice Address - Country:US
Practice Address - Phone:458-210-2984
Practice Address - Fax:458-210-2985
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096007206RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse