Basic Information
| Provider Information | |||||||||
| NPI: | 1689149361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELINE | ||||||||
| FirstName: | MYRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3614 EMERALD ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974054329 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1515 VILLAGE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974249700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417675200 | ||||||||
| FaxNumber: | 5417675288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201808281RN | OR | N | Nursing Service Providers | Registered Nurse | 363L00000X | 201809683NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.