Healthcare Provider Details

I. General information

NPI: 1700069408
Provider Name (Legal Business Name): CHRISTINE SUSANNE MAGILL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 NW SAMARITAN DR STE 100
CORVALLIS OR
97330-3738
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD-330
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA153130
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: