Individual
HAZEN TIMOTHY HERZOG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHYSICIAN ASSISTANT
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
7462373-1206
UT
363AS0400X
Surgical Physician Assistant
Primary
PA152638
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1407812365
GROUP NPI NORTH BEND MEDICAL CENTER
OR
01
—
161133
GROUP MEDICAID NORTH BEND MEDICAL CENTER
OR
05
—
500625533
—
OR
01
—
74623731206
LICENSE
UT
01
—
93-0635514
GROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER
OR
01
—
P01220506
RAILROAD MEDICARE
OR
01
—
PA152638
MEDICAL LICENSE
OR
01
—
R000WFBTV
GROUP MEDICARE NORTH BEND MEDICAL CENTER
OR
Enumeration date
09/21/2009
Last updated
11/08/2013
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