Provider Demographics
NPI:1740819002
Name:SURBER, SHEFFIE DAN JR (LPN)
Entity type:Individual
Prefix:
First Name:SHEFFIE
Middle Name:DAN
Last Name:SURBER
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:2575 WESTGATE BLDG 13
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9613
Practice Address - Country:US
Practice Address - Phone:541-429-8721
Practice Address - Fax:541-429-8720
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20030441LPN164W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse