Provider Demographics
NPI:1164770988
Name:HAZEN, JAIME (OD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:HAZEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:BALZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:404 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2910
Mailing Address - Country:US
Mailing Address - Phone:307-322-9747
Mailing Address - Fax:
Practice Address - Street 1:404 9TH ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2910
Practice Address - Country:US
Practice Address - Phone:307-322-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY340T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1164770988Medicaid
WY1164770988Medicare NSC