Healthcare Provider Details

I. General information

NPI: 1609158161
Provider Name (Legal Business Name): HAILEY MARIE GARSIDE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

IV. Provider business mailing address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-6313
  • Fax: 541-389-8760
Mailing address:
  • Phone: 541-389-6313
  • Fax: 541-389-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number201150119NP
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500639022
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: