Provider Demographics
NPI:1245481761
Name:FOOTE, ERIC LEE (PA-C)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LEE
Last Name:FOOTE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:18610 NW CORNELL RD
Practice Address - Street 2:STE 101
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9206
Practice Address - Country:US
Practice Address - Phone:503-216-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01392363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500629100Medicaid
ORR166191Medicare PIN
ORR166193Medicare PIN
ORR168834Medicare PIN
ORR166192Medicare PIN
ORR166194Medicare PIN
ORR166195Medicare PIN
ORR167115Medicare PIN