Provider Demographics
NPI:1942575881
Name:FERGUSON, GREG CLARKE (RPH RN)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:CLARKE
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:RPH RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3744
Mailing Address - Country:US
Mailing Address - Phone:503-816-5421
Mailing Address - Fax:
Practice Address - Street 1:4522 SE LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3744
Practice Address - Country:US
Practice Address - Phone:503-816-5421
Practice Address - Fax:503-816-5421
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8139183500000X
OR094000338163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No183500000XPharmacy Service ProvidersPharmacist