Provider Demographics
NPI:1861293284
Name:SOUTHERN OREGON GYNECOLOGY LLC
Entity type:Organization
Organization Name:SOUTHERN OREGON GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:NP, CNM
Authorized Official - Phone:541-500-4747
Mailing Address - Street 1:1910 E BARNETT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8672
Mailing Address - Country:US
Mailing Address - Phone:541-500-4747
Mailing Address - Fax:
Practice Address - Street 1:1910 E BARNETT RD STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8672
Practice Address - Country:US
Practice Address - Phone:541-500-4747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty