Healthcare Provider Details

I. General information

NPI: 1659489722
Provider Name (Legal Business Name): MARVIN HAROLD MCALLISTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-9303
  • Fax: 541-868-9306
Mailing address:
  • Phone: 541-868-9303
  • Fax: 541-868-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00908
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: