Provider Demographics
NPI:1700830379
Name:CAMPAGNA, PAUL ANTHONY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:CAMPAGNA
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 1:610 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-8602
Mailing Address - Country:US
Mailing Address - Phone:541-667-3732
Mailing Address - Fax:541-667-3731
Practice Address - Street 1:600 NW 11TH ST
Practice Address - Street 2:E37
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-8602
Practice Address - Country:US
Practice Address - Phone:541-667-3732
Practice Address - Fax:541-667-3731
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD129322080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213051Medicaid
ORF22949Medicare UPIN
OR383985Medicare ID - Type Unspecified