Provider Demographics
NPI:1083091029
Name:PATTILLO, PAIGE (NP)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:PATTILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 CAMP BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-9605
Mailing Address - Country:US
Mailing Address - Phone:541-841-6132
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:205-936-1386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-054204363LF0000X, 363LP2300X
OR201601264NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201601263RNOtherOREGON STATE BOARD OF NURSING
OR201602164NP-PPOtherOREGON STATE BOARD OF NURSING