Provider Demographics
NPI:1154330215
Name:CUNLIFFE, RICHARD DANIEL (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DANIEL
Last Name:CUNLIFFE
Suffix:
Gender:M
Credentials:PAC
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 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4812
Mailing Address - Fax:541-684-3074
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-242-4812
Practice Address - Fax:541-684-3074
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605567Medicaid
OR133465Medicare ID - Type Unspecified