Provider Demographics
NPI:1801914734
Name:SKINNER, IDA B (RNFA)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:B
Last Name:SKINNER
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 NW SAMARITAN DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3783
Mailing Address - Country:US
Mailing Address - Phone:541-768-5930
Mailing Address - Fax:
Practice Address - Street 1:3615 NW SAMARITAN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3783
Practice Address - Country:US
Practice Address - Phone:541-768-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR180151364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090487Medicaid