Basic Information
| Provider Information | |||||||||
| NPI: | 1043474448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAYNER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1648 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424172 | ||||||||
| FaxNumber: | 5412424171 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 210B | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424172 | ||||||||
| FaxNumber: | 5412424171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 07/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5710 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 218714 | 05 | OR | MEDICAID |