Basic Information
| Provider Information | |||||||||
| NPI: | 1508421751 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PACE | ||||||||
| FirstName: | ETHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4749 | ||||||||
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| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975010227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894111 | ||||||||
| FaxNumber: | 5417895518 | ||||||||
| Practice Location | |||||||||
| Address1: | 3011 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894673 | ||||||||
| FaxNumber: | 5417892121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2019 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | PA197772 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.