Provider Demographics
NPI:1023351418
Name:SHULTZ, VICTORIA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ANN
Other - Last Name:PENNA / WALTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 HARTMAN LN STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1122
Mailing Address - Country:US
Mailing Address - Phone:541-334-3350
Mailing Address - Fax:541-343-3459
Practice Address - Street 1:2400 HARTMAN LN STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1122
Practice Address - Country:US
Practice Address - Phone:541-334-3350
Practice Address - Fax:541-343-3459
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA169767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500677698Medicaid
ORR177121Medicare PIN