Provider Demographics
NPI:1306494638
Name:TETZLAFF, HAZEL JADE MILANO (PA-C)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:JADE MILANO
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HAZEL
Other - Middle Name:JADE
Other - Last Name:MILANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 ELM ST SW STE 300
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1958
Practice Address - Country:US
Practice Address - Phone:541-812-4580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1166933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant