Provider Demographics
NPI:1104906981
Name:BLAKER, DEBRA SUSAN (FNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUSAN
Last Name:BLAKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 JEFFERSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2414
Mailing Address - Country:US
Mailing Address - Phone:541-284-8882
Mailing Address - Fax:541-284-2826
Practice Address - Street 1:1902 JEFFERSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-2414
Practice Address - Country:US
Practice Address - Phone:541-284-8882
Practice Address - Fax:541-284-2826
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090006820N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119349Medicare PIN
ORP20615Medicare UPIN