Provider Demographics
NPI:1043365513
Name:HUNTLEY, DOUGLAS DUANE (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DUANE
Last Name:HUNTLEY
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 1:1377 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2037
Mailing Address - Country:US
Mailing Address - Phone:503-769-8470
Mailing Address - Fax:503-769-9860
Practice Address - Street 1:1377 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-8470
Practice Address - Fax:503-769-9860
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00977363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500614409Medicaid