Healthcare Provider Details

I. General information

NPI: 1821516287
Provider Name (Legal Business Name): JAIME WASIK RN, MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

3873 GLENHAVEN WAY
KINGMAN AZ
86409-4909
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax:
Mailing address:
  • Phone: 928-303-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202001769NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10563
License Number StateAZ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: