Healthcare Provider Details

I. General information

NPI: 1053153452
Provider Name (Legal Business Name): CENTRAL OREGON PEDIATRIC ASSOCIATES SUBSPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

IV. Provider business mailing address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-6313
  • Fax:
Mailing address:
  • Phone: 541-389-6313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VALERIE SHINE
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 541-389-6313