Provider Demographics
NPI:1043386717
Name:PETHTEL, ELIZABETH L (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:PETHTEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-864-8900
Mailing Address - Fax:541-245-3315
Practice Address - Street 1:3170 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-864-8900
Practice Address - Fax:541-245-3315
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORO85072196363LF0000X
OR085072196N1363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112651Medicaid
ORNP (36)OtherDMAP
C42479Medicare UPIN
OR112651Medicare ID - Type Unspecified