Provider Demographics
NPI:1396759916
Name:TRUBENBACH, THOMAS JASON (FNP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JASON
Last Name:TRUBENBACH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E BARNETT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8225
Mailing Address - Country:US
Mailing Address - Phone:541-779-5007
Mailing Address - Fax:541-779-2055
Practice Address - Street 1:1311 E BARNETT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8225
Practice Address - Country:US
Practice Address - Phone:541-779-5007
Practice Address - Fax:541-779-2055
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550156NP363LF0000X
OR200040988RN163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297670Medicaid
OR297670Medicaid
ORQ58140Medicare UPIN