Healthcare Provider Details

I. General information

NPI: 1326082488
Provider Name (Legal Business Name): JONATHAN CONIGLIO PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 E BARNETT RD STE 200
MEDFORD OR
97504-8674
US

IV. Provider business mailing address

2780 E BARNETT RD STE 200
MEDFORD OR
97504-8674
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-6250
  • Fax: 541-608-2535
Mailing address:
  • Phone: 541-779-6250
  • Fax: 541-608-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA201555
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: