Provider Demographics
NPI:1043474448
Name:WAYNER, ROBERT AARON (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:AARON
Last Name:WAYNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4172
Mailing Address - Fax:541-242-4171
Practice Address - Street 1:920 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 210B
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:541-242-4172
Practice Address - Fax:541-242-4171
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218714Medicaid
ORR152599Medicare PIN