Healthcare Provider Details

I. General information

NPI: 1821574625
Provider Name (Legal Business Name): EDITHA C SETIAWAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S GARDEN WAY STE 350
EUGENE OR
97401-8179
US

IV. Provider business mailing address

PO BOX 1648
EUGENE OR
97440-1648
US

V. Phone/Fax

Practice location:
  • Phone: 541-746-6816
  • Fax: 541-726-3177
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA209640
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: