Healthcare Provider Details

I. General information

NPI: 1245222322
Provider Name (Legal Business Name): CODY KEITH WASNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 HARLOW RD STE 210
SPRINGFIELD OR
97477-7126
US

IV. Provider business mailing address

PO BOX 1648
EUGENE OR
97440-1648
US

V. Phone/Fax

Practice location:
  • Phone: 541-741-0387
  • Fax: 541-242-4634
Mailing address:
  • Phone: 541-242-4384
  • Fax: 541-463-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number12537
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: