Healthcare Provider Details

I. General information

NPI: 1508400979
Provider Name (Legal Business Name): ROBERT WILLIAM DOLAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 200
BEND OR
97701-4281
US

IV. Provider business mailing address

1600 STATE ST
SALEM OR
97301-4257
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3344
  • Fax: 541-382-1681
Mailing address:
  • Phone: 503-540-6400
  • Fax: 503-540-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA192557
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA192557
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: