Healthcare Provider Details

I. General information

NPI: 1437505534
Provider Name (Legal Business Name): IRMA GABRIELA LAINEZ PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NW HIGHWAY 101 STE A
LINCOLN CITY OR
97367-3241
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-996-7480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA185734
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: