Basic Information
| Provider Information | |||||||||
| NPI: | 1891018461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAIAZZO | ||||||||
| FirstName: | JAIMIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970159777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | 5035718977 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970159777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | 5035718977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA159681 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 500647979 | 05 | OR | MEDICAID |