Basic Information
| Provider Information | |||||||||
| NPI: | 1790755650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANG | ||||||||
| FirstName: | N. | ||||||||
| MiddleName: | LUCAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24410 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974020451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419844301 | ||||||||
| FaxNumber: | 5419027533 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419979650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01282 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 276263 | 05 | OR | MEDICAID |