Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LC1500X | Nurse Practitioner - Community Health | 085072196N1 | OR |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | O85072196 | OR |
NPI | 1043386717 |
---|---|
Provider Name | Elizabeth L Pethtel |
First Address | Medford, OR 97504-8450 |
Second Address | Medford, OR 97504-8450 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/11/2006 |
Last Update Date | 28/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
112651 | (05) | OR |
C42479 | (02) | |
NP (36) | DMAP (01) | OR |