Crater Lake Medical South – Family Nurse Practitioner, NPI 1447752035
Family Nurse Practitioner
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Crater Lake Medical South
PO BOX 508
SHADY COVE, OR 975390508
Phone: (541) 878-2022
Fax: (541) 878-1498
Type: Mailing
21990 HIGHWAY 62
SHADY COVE, OR 975399717
Phone: (541) 878-2022
Fax: (541) 878-1498
Type: Location
Northwest Hawthorne Avenue, Grants Pass, Josephine County, Oregon, 97526, United States
GRANTS PASS, OR 975266009
Phone: (541) 916-8530
Fax: (541) 916-8533
Type: Mailing
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.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2018-03-22
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2024-08-31 (646 days ago).
Enrollment records
1
Earliest due date
2024-08-31
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20180322001584 | O | Clinic/Group Practice | OR | 2024-08-31 |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
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 97539)
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