Healthcare Provider Details

I. General information

NPI: 1760880843
Provider Name (Legal Business Name): NICHOLAS DEAN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 1194
CORVALLIS OR
97339-1194
US

V. Phone/Fax

Practice location:
  • Phone: 541-996-7480
  • Fax: 541-557-6439
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA179857
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: