Provider Demographics
NPI:1619048469
Name:EMBERLIN, MOLLY GRACE (PAC, MS)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:GRACE
Last Name:EMBERLIN
Suffix:
Gender:F
Credentials:PAC, MS
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 COBURG RD
Mailing Address - Street 2:SLOCUM ORTHOPEDICS PC
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2433
Mailing Address - Country:US
Mailing Address - Phone:541-485-8111
Mailing Address - Fax:541-868-0883
Practice Address - Street 1:55 COBURG RD
Practice Address - Street 2:SLOCUM ORTHOPEDICS PC
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2433
Practice Address - Country:US
Practice Address - Phone:541-485-8111
Practice Address - Fax:541-868-0883
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127250Medicare PIN
ORQ78238Medicare UPIN