Individual
NICOLE DIANNE WYDRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1740 NW 9TH ST, CORVALLIS, OR 97330-2141
(541) 230-1350
(541) 207-3477
Mailing address
1740 NW 9TH ST, CORVALLIS, OR 97330-2141
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
—
—
363AM0700X
Medical Physician Assistant
Primary
PA153450
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500617735
—
OR
Enumeration date
08/31/2006
Last updated
11/03/2015
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