Provider Demographics
NPI:1356812291
Name:FEDEROFF, DAVID LAWRENCE (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:FEDEROFF
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:PO BOX 1193
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MULLINS DR STE 2
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3985
Practice Address - Country:US
Practice Address - Phone:541-451-7915
Practice Address - Fax:541-451-7973
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56220363AM0700X
ORPA195905363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical