Provider Demographics
NPI:1932433190
Name:HERZOG, HAZEN TIMOTHY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:HAZEN
Middle Name:TIMOTHY
Last Name:HERZOG
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7462373-1206363A00000X
ORPA152638363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
OR500625533Medicaid
UT74623731206OtherLICENSE
ORP01220506OtherRAILROAD MEDICARE
ORR000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
OR93-0635514OtherGROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER
ORPA152638OtherMEDICAL LICENSE
UT74623731206OtherLICENSE