Healthcare Provider Details

I. General information

NPI: 1043365513
Provider Name (Legal Business Name): DOUGLAS DUANE HUNTLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 N 10TH AVE
STAYTON OR
97383-2037
US

IV. Provider business mailing address

1377 N 10TH AVE
STAYTON OR
97383-2037
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-8470
  • Fax: 503-769-9860
Mailing address:
  • Phone: 503-769-8470
  • Fax: 503-769-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00977
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: