=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346243524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA MARIE SEEDS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 SUNSET DR STE F
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-663-3100
-----------------------------------------------------
Fax | 541-975-5135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3290
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850-7290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-963-1967
-----------------------------------------------------
Fax | 541-963-1837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 004413
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA180691
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------