Provider Demographics
NPI:1982925301
Name:DUSENBURY, NICOLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:DUSENBURY
Suffix:
Gender:F
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 1:5050 SKYLINE VILLAGE LOOP S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9490
Mailing Address - Country:US
Mailing Address - Phone:035-391-1110
Mailing Address - Fax:
Practice Address - Street 1:5050 SKYLINE VILLAGE LOOP S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9490
Practice Address - Country:US
Practice Address - Phone:035-391-1110
Practice Address - Fax:503-370-4237
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014584-1363A00000X
PAMA054809363A00000X
HIAMD -- 581363A00000X
ORPA207501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant