Unknown Individual – Medical Physician Assistant, NPI 1063569242

Unknown Individual is a healthcare provider. based in Medford, Oregon. specializing in Medical Physician Assistant. They hold a License No. PA164765 (OR). The NPI Number for Unknown Individual is 1063569242

Main info

Organization
Inactive
31 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1063569242
Phone
(541) 789-4281
Address
2620 EAST BARNETT RD
Deactivation Date
18 January 2023

Doctor Profile

Medical School Name
OTHER
Secondary Phone
-
Graduation Year
1995 (31 years ago)
PAC ID
2466679865
Group Practice PAC ID
5294623245
Professional Enrollment ID
I20140807002698

Contacts

Secure Messaging
jodea668839@oc.providencedirect.org
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience23
Completeness85
Years active:0State licenses:2Other namesUpdated within 12 months

Provider Addresses for Unknown Individual

  • 2620, East Barnett Road, Medford, Jackson County, Oregon, 97504, United States

    SUITE H

    MEDFORD, OR 975048383

    Phone: (541) 789-4281

    Fax: (541) 789-5538

    Type: Mailing

  • PO BOX 3158

    PORTLAND, OR 972083158

    Phone: (541) 732-6000

    Type: Mailing

  • 965 ELLENDALE DR

    MEDFORD, OR 975048215

    Phone: (541) 732-6000

    Type: Location

  • Asante Rogue Regional Medical Center, 2825, East Barnett Road, Medford, Jackson County, Oregon, 97504, United States

    MEDFORD, OR 975048332

    Phone: (541) 789-7000

    Fax: (415) 600-1298

    Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 97504)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 5294623245View full group profile

Reviews

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Frequently asked questions

What number should I use to identify Unknown Individual for billing?
Administrative and clinical systems typically use NPI 1063569242 for Unknown Individual.
What happens when Unknown Individual's NPI is not active?
Public data lists Unknown Individual outside the active bucket for this identifier.
What type of care does Unknown Individual provide?
Unknown Individual's profile centers on Medical Physician Assistant. Clinical services aligned with this taxonomy classification.
What geographic area is tied to Unknown Individual?
Unknown Individual is associated with Medford, Oregon in the same public data insurers reference.
What is the difference between NPI and a medical license?
An NPI is a federal identifier; a medical license is issued by a state and governs where someone may practice.

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