Healthcare Provider Details

I. General information

NPI: 1639937170
Provider Name (Legal Business Name): FAIR WINDS DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 NW PROFESSIONAL DR
CORVALLIS OR
97330-3991
US

IV. Provider business mailing address

2430 NW PROFESSIONAL DR
CORVALLIS OR
97330-3991
US

V. Phone/Fax

Practice location:
  • Phone: 541-230-1350
  • Fax:
Mailing address:
  • Phone: 541-452-0180
  • Fax: 541-427-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KATIE HATSUSHI
Title or Position: OFFICE MANAGER
Credential: MD
Phone: 408-480-7500