Healthcare Provider Details

I. General information

NPI: 1467479931
Provider Name (Legal Business Name): RONALD A SMITH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1162 WILLAMETTE ST
EUGENE OR
97401-3568
US

IV. Provider business mailing address

PO BOX 24410
EUGENE OR
97402-0451
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-6021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00985
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: