Active NPI
Nicole Dianne Wydra, PA-C
- Medical Physician Assistant
- Corvallis, OR
National Provider Identifier
1962514836
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- PA153450
- Practice address
- 1740 NW 9TH St
Corvallis, OR 97330-2141 - Phone
- (541) 230-1350
- Fax
- (541) 207-3477
- NPI assigned
- Aug 31, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA153450 | OR | Primary |
| Physician Assistant | 363A00000X |
Addresses
Primary practice location
1740 NW 9TH St
Corvallis, OR 97330-2141
Mailing address
1740 NW 9TH St
Corvallis, OR 97330-2141
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500617735 | Medicaid | OR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OR
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Physician Assistant
- Education
- Loma Linda University School of Medicine, 2010
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
Practice addresses (Care Compare)
1740 NW 9TH St
Corvallis, OR 97330-2141
Phone (541) 230-1350
Hospital & facility affiliations
Merit-based Incentive Payment System (MIPS)
- Final score
- 95.31 of 100
- Quality
- 90.62
- Improvement activities
- 40
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA153450 | OR | MD | Medical Physician Assistant |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dermatology Physician
- Corvallis, OR
- NPI 1093037210
Hospital & facility affiliations 17
Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.
-
- General Acute Care Hospital
- Albany, OR
- NPI 1154372340
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Albany, OR
- NPI 1326755158
Hospital
-
- Endocrinology, Diabetes & Metabolism Physician
- Albany, OR
- NPI 1346620408
Hospital
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156982400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1446508800000",
"number": "1962514836",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1740 NW 9TH ST",
"city": "CORVALLIS",
"state": "OR",
"postal_code": "973302141"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1740 NW 9TH ST",
"city": "CORVALLIS",
"state": "OR",
"postal_code": "973302141",
"telephone_number": "541-230-1350",
"fax_number": "541-207-3477"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WYDRA",
"first_name": "NICOLE",
"middle_name": "DIANNE",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-31",
"last_updated": "2015-11-03",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "OR",
"license": "PA153450",
"primary": true
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500617735",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Corvallis, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.