Unknown Individual – Family Medicine Physician, NPI 1184935876

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Lakeview, Oregon. specializing in Family Medicine Physician. They hold a License No. MD156107 (OR). The NPI Number for Unknown Individual is 1184935876

Main info

Organization

Inactive

18 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1184935876

Phone

(419) 473-3665

Address

700 S J ST

Deactivation Date

11 March 2022

Doctor Profile

Medical School Name

GEORGETOWN UNIVERSITY SCHOOL OF MEDICINE

Secondary Phone

5419472114

Graduation Year

2008 (18 years ago)

PAC ID

2860659984

Group Practice PAC ID

4284629221

Professional Enrollment ID

I20120201000551

Contacts

Secure Messaging

800875@lake.cernerdirect.com

Data current as of

20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience19

Completeness85

Years active:0State licenses:1Other namesUpdated within 12 months

Provider Addresses for Unknown Individual

700 S J ST
LAKEVIEW, OR 976301623
Phone: (419) 473-3665
Fax: (541) 947-4407
Type: Mailing
700 S J St
Lakeview, OR 97630
Phone: (541) 947-3366
Fax: (541) 947-4407
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 97630)

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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: 4284629221View full group profile

Name	Specialty	State
MS. ELLEN EDITH MOUSER (PMHNP)	-	IL
DR. CASEY GEORGE CURRAN (MD)	Diagnostic Radiology	OR
DR. MARK F BRADBURY (M.D.)	General Surgery, Thoracic Surgery	OR
MRS. LESA L CAHILL (FNP)	Nurse Practitioner	OR
DR. CYNTHIA S.B. TUCKER (MD)	O B S T E T R I C S/ G Y N E C O L O G Y	CO
DR. DAVID MARSHALL AGER (D.C.)	C H I R O P R A C T I C	OR
JACI MARIE MASTRANDREA (APRN, FNP-C)	Nurse Practitioner	OR
DR. WESLEY JAMES STEVENS (DO)	-	CA
MS. KATHLEEN J. THOMPSON (PA-C)	-	OR
BARD L ROGERS (M.D.)	Family Practice	NM