Provider Demographics
NPI:1316944754
Name:HAZEL, TOM DAVID (FNP)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:DAVID
Last Name:HAZEL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1552
Mailing Address - Country:US
Mailing Address - Phone:541-201-4800
Mailing Address - Fax:541-201-4815
Practice Address - Street 1:560 CATALINA DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1605
Practice Address - Country:US
Practice Address - Phone:541-201-4800
Practice Address - Fax:541-201-4815
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083042659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR032842Medicaid
OR136114Medicaid
OR380005Medicare Oscar/Certification
OR032842Medicaid