Healthcare Provider Details

I. General information

NPI: 1235571936
Provider Name (Legal Business Name): NATHAN WAYNE SCADLOCK DNP, ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 CHAMBERS ST
EUGENE OR
97402-3636
US

IV. Provider business mailing address

PO BOX 1648
EUGENE OR
97440-1648
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1711
  • Fax: 541-686-6018
Mailing address:
  • Phone: 541-687-4900
  • Fax: 541-463-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number201900807NP-PP
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500760659
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: