Provider Demographics
NPI:1578921003
Name:CHURCHMAN, ELYSIA
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:CHURCHMAN
Suffix:
Gender:F
Credentials:
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 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:1140 SW SIMPSON AVE STE 110
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3789
Practice Address - Country:US
Practice Address - Phone:541-389-7741
Practice Address - Fax:541-278-8375
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175099363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR186235Medicare PIN