Provider Demographics
NPI:1043546534
Name:WALDIE, JEREMY GAYLON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:GAYLON
Last Name:WALDIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 OWENS ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4183
Mailing Address - Country:US
Mailing Address - Phone:503-399-1400
Mailing Address - Fax:503-399-1406
Practice Address - Street 1:374 OWENS ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4183
Practice Address - Country:US
Practice Address - Phone:503-399-1400
Practice Address - Fax:503-399-1406
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA165500363A00000X
WAPA60120298363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50071199Medicaid