Provider Demographics
NPI:1992747265
Name:HAZE, CORA MAY (PA)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:MAY
Last Name:HAZE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-1020
Mailing Address - Country:US
Mailing Address - Phone:541-582-0505
Mailing Address - Fax:541-582-0778
Practice Address - Street 1:509 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9674
Practice Address - Country:US
Practice Address - Phone:541-582-0505
Practice Address - Fax:541-582-0778
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00000Medicaid
OR00000Medicaid
ORQ26453Medicare UPIN