Provider Demographics
NPI:1215212840
Name:NIGHTINGALE, JOHN M (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:NIGHTINGALE
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 1194
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 NW HIGHWAY 101 STE A
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-3241
Practice Address - Country:US
Practice Address - Phone:541-994-7480
Practice Address - Fax:541-557-6439
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant