Provider Demographics
NPI:1124105838
Name:FERGUSON, STANLEY R (PA-C)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SW 9TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4895
Mailing Address - Country:US
Mailing Address - Phone:541-265-2007
Mailing Address - Fax:541-265-3533
Practice Address - Street 1:775 SW 9TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4895
Practice Address - Country:US
Practice Address - Phone:541-265-2007
Practice Address - Fax:541-265-3533
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00220363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110047682OtherRR MEDICARE
OR110047682OtherRR MEDICARE
ORR91972Medicare UPIN