Provider Demographics
NPI:1558581025
Name:GIANCARLO, PAUL W
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:GIANCARLO
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 1:1109 SISKIYOU BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-3941
Mailing Address - Country:US
Mailing Address - Phone:541-482-7070
Mailing Address - Fax:541-708-6500
Practice Address - Street 1:1109 SISKIYOU BLVD STE B
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-3941
Practice Address - Country:US
Practice Address - Phone:541-482-7070
Practice Address - Fax:541-708-6500
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL27911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR104032Medicare ID - Type Unspecified
ORR104032Medicare PIN