Provider Demographics
NPI:1093936486
Name:BAZ, BRONWYN (MD)
Entity Type:Individual
Prefix:
First Name:BRONWYN
Middle Name:
Last Name:BAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRONWYN
Other - Middle Name:MB
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-652-2880
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96638208000000X
ORMD28390208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD28390OtherOREGON MEDICAL LICENSE
CA00A966380Medicaid