Healthcare Provider Details

I. General information

NPI: 1225685266
Provider Name (Legal Business Name): EVON PRASKA AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 12/27/2021
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 SW BOND ST
BEND OR
97702-3593
US

IV. Provider business mailing address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-4900
  • Fax:
Mailing address:
  • Phone: 541-382-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number030956
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500787754
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: