Provider Demographics
NPI:1104861798
Name:TEMPLE, PHYLLIS (FNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:541-984-4301
Mailing Address - Fax:
Practice Address - Street 1:200 N MONROE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-4243
Practice Address - Country:US
Practice Address - Phone:541-686-1427
Practice Address - Fax:541-341-1693
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR85073091N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210911Medicaid
S89635Medicare UPIN
OR210911Medicaid
ORRR PTAN 500007808Medicare PIN