Provider Demographics
NPI:1497088728
Name:EBERT, MAGGIE EILEEN (PA)
Entity Type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:EILEEN
Last Name:EBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MAGGIE
Other - Middle Name:EILEEN
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3640 NW SAMARITAN DR STE 100A
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3784
Practice Address - Country:US
Practice Address - Phone:541-768-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA150183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant