Healthcare Provider Details

I. General information

NPI: 1316944754
Provider Name (Legal Business Name): TOM DAVID HAZEL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 TALENT AVE
TALENT OR
97540-9638
US

IV. Provider business mailing address

1221 DISK DR
MEDFORD OR
97501-6638
US

V. Phone/Fax

Practice location:
  • Phone: 541-773-3863
  • Fax:
Mailing address:
  • Phone: 458-658-5930
  • Fax: 541-414-1123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number083042659
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: