Basic Information
| Provider Information | |||||||||
| NPI: | 1245843143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SICKELTON | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | LEE DAVID | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18565 W BASELINE RD APT 508 | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970062941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054231064 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1028 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | OR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA201952 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.