=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962041707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIFT BEND FUNCTIONAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2019
-----------------------------------------------------
Last Update Date | 12/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 SW SHEVLIN HICKS DR SUITE #1
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-219-1910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 NW TRENTON AVE
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97703-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-219-1910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND MEDICAL PROVIDER
-----------------------------------------------------
Name | DR. MARIE AGNEW
-----------------------------------------------------
Credential | FNP-C, DNP
-----------------------------------------------------
Telephone | 541-219-1910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------