MEDICARE: WANDA CAROL NEWSOME CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	201908923NP-PP	OR
2	363LF0000X	Family Nurse Practitioner	R870610	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01341901	OTHER	MS	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	9876741	OTHER	MS	AETNA

General Provider Information

NPI Number	:	1306129614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA CAROL NEWSOME CNP

Provider Business Mailing Address
First Line	:	PO BOX 579
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97339-0579
Country	:	US
Telephone Number	:	541-766-0174
Fax Number	:	541-766-6164

Provider Business Practice Location Address
First Line	:	100 MULLINS DR STE A1
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-2868
Country	:	US
Telephone Number	:	541-766-0200
Fax Number	:	541-766-6618

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	12/18/2024

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Directions to “ WANDA CAROL NEWSOME CNP” Practice Location

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