Basic Information
| Provider Information | |||||||||
| NPI: | 1932433190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | HAZEN | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2009 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7462373-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA152638 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 161133 | 01 | OR | GROUP MEDICAID NORTH BEND MEDICAL CENTER | OTHER | 500625533 | 05 | OR | MEDICAID | 74623731206 | 01 | UT | LICENSE | OTHER | P01220506 | 01 | OR | RAILROAD MEDICARE | OTHER | R000WFBTV | 01 | OR | GROUP MEDICARE NORTH BEND MEDICAL CENTER | OTHER | 1407812365 | 01 | OR | GROUP NPI NORTH BEND MEDICAL CENTER | OTHER | 93-0635514 | 01 | OR | GROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER | OTHER | PA152638 | 01 | OR | MEDICAL LICENSE | OTHER |