Provider Demographics
NPI:1518934751
Name:FIACCO, REGINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:FIACCO
Suffix:
Gender:F
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 1:890 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3233
Mailing Address - Country:US
Mailing Address - Phone:541-688-0674
Mailing Address - Fax:541-688-5378
Practice Address - Street 1:890 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3233
Practice Address - Country:US
Practice Address - Phone:541-688-0674
Practice Address - Fax:541-688-5378
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004938363AM0700X
ORPA158680363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
8441628OtherDSHS
WA8441628Medicaid
WA221417OtherL&I
WAG8858151Medicare PIN
WA221417OtherL&I