Provider Demographics
NPI:1841397742
Name:BANCROFT, CLYDE TERRENCE (PA)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:TERRENCE
Last Name:BANCROFT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3362
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3362
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601499Medicaid
OR500601499Medicaid
OR115679Medicare ID - Type Unspecified