Healthcare Provider Details

I. General information

NPI: 1518934751
Provider Name (Legal Business Name): REGINA M. FIACCO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 NW SPRUCE AVE
CORVALLIS OR
97330-2111
US

IV. Provider business mailing address

981 NW SPRUCE AVE
CORVALLIS OR
97330-2111
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-0766
  • Fax:
Mailing address:
  • Phone: 541-758-0766
  • Fax: 541-753-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA158680
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004938
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: