Provider Demographics
NPI:1124014956
Name:WAYSON, KIM A (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:WAYSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-297-3766
Mailing Address - Fax:503-296-1168
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 440
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-3766
Practice Address - Fax:503-296-1168
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD13269207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR155754Medicaid
0000WCJQWMedicare ID - Type Unspecified
OR155754Medicaid