Healthcare Provider Details

I. General information

NPI: 1063647949
Provider Name (Legal Business Name): WRAZEN & RASH PC, PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 SW 9TH STREET ANNEX A
NEWPORT OR
97365
US

IV. Provider business mailing address

775 SW 9TH STREET ANNEX A
NEWPORT OR
97365
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-5362
  • Fax: 541-265-9304
Mailing address:
  • Phone: 541-265-5362
  • Fax: 541-265-9304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD17873
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier073994
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: SEAN MICHAEL RASH
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 541-265-5362