Basic Information
| Provider Information | |||||||||
| NPI: | 1417928672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974701281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416774313 | ||||||||
| FaxNumber: | 5416774533 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974701281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416774313 | ||||||||
| FaxNumber: | 5416774533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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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 | PA00510 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 165878 | 05 | OR | MEDICAID | 970012159 | 01 | OR | RAILROAD MEDICARE | OTHER |