Healthcare Provider Details

I. General information

NPI: 1316331259
Provider Name (Legal Business Name): SUSAN PATRICIA ANDUAGA BOCANEGRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3499
US

IV. Provider business mailing address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3499
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-7565
  • Fax: 503-626-4418
Mailing address:
  • Phone: 503-643-7565
  • Fax: 503-626-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58314
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58314
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: