Provider Demographics
NPI:1801841960
Name:PENDRAGON, ELIZABETH TYRELL (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:TYRELL
Last Name:PENDRAGON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:TYRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:633 N ALBANY RD NW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1433
Practice Address - Country:US
Practice Address - Phone:541-926-3441
Practice Address - Fax:541-926-1010
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65070207Q00000X
ORMD208773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA65070BMedicare Oscar/Certification
CAH14533Medicare UPIN