Basic Information
| Provider Information | |||||||||
| NPI: | 1467996553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFREY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5033640775 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5033640775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2016 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA181080 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.