Basic Information
| Provider Information | |||||||||
| NPI: | 1275525719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITAK | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415934111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25647 REDWOOD HWY | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975319724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415924111 | ||||||||
| FaxNumber: | 5415923916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA00614 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 237479 | 05 | OR | MEDICAID |