Healthcare Provider Details

I. General information

NPI: 1669745469
Provider Name (Legal Business Name): DANIELLE KATHRYN ADDLEMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE KATHRYN GIPSON PA

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 SW PERKINS AVE
PENDLETON OR
97801-4302
US

IV. Provider business mailing address

2450 SW PERKINS AVE
PENDLETON OR
97801-4302
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-1700
  • Fax: 541-276-6327
Mailing address:
  • Phone: 541-276-1700
  • Fax: 541-276-6327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA164124
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500666136
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: