Healthcare Provider Details

I. General information

NPI: 1124105838
Provider Name (Legal Business Name): STANLEY R FERGUSON P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 SW 9TH ST SUITE B
NEWPORT OR
97365-4895
US

IV. Provider business mailing address

775 SW 9TH ST SUITE B
NEWPORT OR
97365-4895
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-2007
  • Fax: 541-265-3533
Mailing address:
  • Phone: 541-265-2007
  • Fax: 541-265-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00220
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: