1508421751 NPI number — ETHAN PACE

Table of content: ETHAN PACE (NPI 1508421751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508421751 NPI number — ETHAN PACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACE
Provider First Name:
ETHAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508421751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4749
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501-0227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-789-4111
Provider Business Mailing Address Fax Number:
541-789-5518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 E BARNETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-789-4673
Provider Business Practice Location Address Fax Number:
541-789-2121
Provider Enumeration Date:
05/02/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  PA197772 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)