Basic Information
| Provider Information | |||||||||
| NPI: | 1659489722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCALLISTER | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | HAROLD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689303 | ||||||||
| FaxNumber: | 5418689306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689303 | ||||||||
| FaxNumber: | 5418689306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00908 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500605196 | 05 | OR | MEDICAID |