MEDICARE: DOUGLAS DUANE HUNTLEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA00977	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043365513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS DUANE HUNTLEY PA-C

Provider Business Mailing Address
First Line	:	1377 N 10TH AVE
Second Line	:
City	:	STAYTON
State	:	OR
Zip	:	97383-2037
Country	:	US
Telephone Number	:	503-769-8470
Fax Number	:	503-769-9860

Provider Business Practice Location Address
First Line	:	1377 N 10TH AVE
Second Line	:
City	:	STAYTON
State	:	OR
Zip	:	97383-2037
Country	:	US
Telephone Number	:	503-769-8470
Fax Number	:	503-769-9860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	04/15/2022

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