1396770582 NPI number — CHRISTOPHER R STURDEVANT PA-C

Table of content: CHRISTOPHER R STURDEVANT PA-C (NPI 1396770582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396770582 NPI number — CHRISTOPHER R STURDEVANT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STURDEVANT
Provider First Name:
CHRISTOPHER
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1396770582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 BENNETT AVE
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-6715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-608-1997
Provider Business Mailing Address Fax Number:
541-772-1553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 HWY 99 N
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-9152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-488-4464
Provider Business Practice Location Address Fax Number:
541-488-3772
Provider Enumeration Date:
07/12/2006

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: 363AM0700X , with the licence number:  PA00801 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: PA00801 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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