Provider Demographics
NPI:1285219428
Name:CANTRELL, CODY RYAN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:RYAN
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 HARTMAN LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1118
Mailing Address - Country:US
Mailing Address - Phone:541-334-3350
Mailing Address - Fax:
Practice Address - Street 1:2400 HARTMAN LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1118
Practice Address - Country:US
Practice Address - Phone:541-334-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA210353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA210353OtherOREGON MEDICAL LICENSE