Healthcare Provider Details

I. General information

NPI: 1114207032
Provider Name (Legal Business Name): FAIROZ RADTKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 LIBERTY ST SE STE 170
SALEM OR
97302-4149
US

IV. Provider business mailing address

960 LIBERTY ST SE STE 170
SALEM OR
97302-4149
US

V. Phone/Fax

Practice location:
  • Phone: 815-578-6109
  • Fax: 312-268-5053
Mailing address:
  • Phone: 815-578-6109
  • Fax: 312-268-5053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number219833
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: