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NPI Code Detail

MEDICARE: FAIROZ RADTKE PA-C

MEDICARE: FAIROZ RADTKE PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant219833OR

General Provider Information

NPI Number : 1114207032
Entity Type Code : Individual
Provider Name (Legal Business Name) : FAIROZ RADTKE PA-C
Provider Business Mailing Address
First Line : 960 LIBERTY ST SE STE 170
Second Line :
City : SALEM
State : OR
Zip : 97302-4149
Country : US
Telephone Number : 815-578-6109
Fax Number : 312-268-5053
Provider Business Practice Location Address
First Line : 960 LIBERTY ST SE STE 170
Second Line :
City : SALEM
State : OR
Zip : 97302-4149
Country : US
Telephone Number : 815-578-6109
Fax Number : 312-268-5053
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/23/2011
Last Update Date : 02/24/2026

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Directions to “ FAIROZ RADTKE PA-C” Practice Location

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