Healthcare Provider Details

I. General information

NPI: 1225880826
Provider Name (Legal Business Name): COLTON JOSEPH DANFORTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 RANCH RD
REEDSPORT OR
97467-1796
US

IV. Provider business mailing address

1813 W HARVARD AVE STE 310
ROSEBURG OR
97471-2756
US

V. Phone/Fax

Practice location:
  • Phone: 541-271-2163
  • Fax: 541-271-4058
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA218705
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: