Healthcare Provider Details

I. General information

NPI: 1710487897
Provider Name (Legal Business Name): PAUL DANIEL FICKES PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 08/20/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S CENTRAL AVE STE 101
MEDFORD OR
97501-7808
US

IV. Provider business mailing address

724 S CENTRAL AVE STE 101
MEDFORD OR
97501-7808
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4222
  • Fax:
Mailing address:
  • Phone: 541-249-7244
  • Fax: 541-325-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201805705NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: