Provider Demographics
NPI:1053353649
Name:DETTWILER, MARGE L (PNP)
Entity type:Individual
Prefix:
First Name:MARGE
Middle Name:L
Last Name:DETTWILER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4464
Mailing Address - Country:US
Mailing Address - Phone:503-364-0227
Mailing Address - Fax:503-364-0364
Practice Address - Street 1:2395 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4464
Practice Address - Country:US
Practice Address - Phone:503-364-0227
Practice Address - Fax:503-364-0364
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000027830N2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269714Medicaid