Provider Demographics
NPI:1073586319
Name:GAMBILL, JON DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DOUGLAS
Last Name:GAMBILL
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:PO BOX 888
Mailing Address - Street 2:115 S PINE STREET
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0888
Mailing Address - Country:US
Mailing Address - Phone:541-839-4211
Mailing Address - Fax:541-839-4983
Practice Address - Street 1:115 S PINE ST
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9648
Practice Address - Country:US
Practice Address - Phone:541-839-4211
Practice Address - Fax:541-839-4983
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00791363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR111732Medicare ID - Type UnspecifiedIND MEDICARE
ORR111732Medicare PIN
ORP72283Medicare UPIN