Healthcare Provider Details

I. General information

NPI: 1053050377
Provider Name (Legal Business Name): KAITLYN ELIZABETH WASZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 ROYAL AVE
MEDFORD OR
97504-6101
US

IV. Provider business mailing address

1170 ROYAL AVE
MEDFORD OR
97504-6101
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-7331
  • Fax:
Mailing address:
  • Phone: 541-779-7331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: