Healthcare Provider Details

I. General information

NPI: 1285666040
Provider Name (Legal Business Name): MARY SHERMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MONROE ST
EUGENE OR
97402-4243
US

IV. Provider business mailing address

51730 DEXTER ST
BLUE RIVER OR
97413-9776
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1427
  • Fax: 541-341-1693
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number80044610N1
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier077024
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: