Provider Demographics
NPI:1093742041
Name:WACEK, PAUL DENNIS (PAC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DENNIS
Last Name:WACEK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 5020
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-371-4044
Practice Address - Fax:503-371-4356
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605090Medicaid
OR500605090Medicaid
OR180167Medicare PIN