Healthcare Provider Details

I. General information

NPI: 1407844525
Provider Name (Legal Business Name): DEIDRE GOLDBERG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 E MCANDREWS RD STE 300
MEDFORD OR
97504-5589
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-7850
  • Fax: 541-732-7851
Mailing address:
  • Phone: 541-732-7850
  • Fax: 541-732-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number82022347
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: