Individual
MR. JEREMY GAYLON WALDIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
374 OWENS ST SE, SALEM, OR 97302-4183
(503) 399-1400
(503) 399-1406
Mailing address
374 OWENS ST SE, SALEM, OR 97302-4183
(503) 399-1400
(503) 399-1406
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA165500
OR
363AM0700X
Medical Physician Assistant
PA60120298
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
50071199
—
OR
Enumeration date
10/19/2009
Last updated
02/13/2020
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