Healthcare Provider Details

I. General information

NPI: 1023051190
Provider Name (Legal Business Name): GREGORY RYAN CALDWELL P.A-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/15/2024
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GOLF VIEW DR
MEDFORD OR
97504-9643
US

IV. Provider business mailing address

2100 POWELL ST STE 920
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 541-494-1111
  • Fax: 541-494-1099
Mailing address:
  • Phone: 510-350-2600
  • Fax: 510-879-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA204347
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: