| Eden Practitioners | |
|
843 E Main St Ste 204 Medford OR 97504-7137 | |
| (541) 329-0478 | |
| (541) 314-9556 |
| Full Name | Eden Practitioners |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 843 E Main St Ste 204, Medford, Oregon |
| Authorized Official Name and Position | Dane Fickes (OWNER) |
| Authorized Official Contact | 5413290478 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Eden Practitioners 843 E Main St Ste 204 Medford OR 97504-7137 Ph: (541) 329-0478 | Eden Practitioners 843 E Main St Ste 204 Medford OR 97504-7137 Ph: (541) 329-0478 |
| NPI Number | 1376219147 |
|---|---|
| Provider Enumeration Date | 08/20/2021 |
| Last Update Date | 08/12/2022 |
| Certification Date | 08/12/2022 |
| Medicare PECOS PAC ID | 0244637684 |
|---|---|
| Medicare Enrollment ID | O20210927003492 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1376219147 | NPI | - | NPPES |
| Provider Name | Malia Louise Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568715456 PECOS PAC ID: 4880022037 Enrollment ID: I20200321000526 |
| Provider Name | Darrell Elliott Benko |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1023538139 PECOS PAC ID: 5597036590 Enrollment ID: I20210201000558 |
| Provider Name | Heather Barraclough |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841954641 PECOS PAC ID: 4082004072 Enrollment ID: I20211207000012 |
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