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NPI Code Detail

MEDICARE: MR. JEREMY GAYLON WALDIE PA-C

MEDICARE: MR. JEREMY GAYLON WALDIE PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA165500OR
2363AM0700XMedical Physician AssistantPA60120298WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1043546534
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JEREMY GAYLON WALDIE PA-C
Provider Business Mailing Address
First Line : 374 OWENS ST SE
Second Line :
City : SALEM
State : OR
Zip : 97302-4183
Country : US
Telephone Number : 503-399-1400
Fax Number : 503-399-1406
Provider Business Practice Location Address
First Line : 374 OWENS ST SE
Second Line :
City : SALEM
State : OR
Zip : 97302-4183
Country : US
Telephone Number : 503-399-1400
Fax Number : 503-399-1406
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2009
Last Update Date : 02/13/2020

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