Healthcare Provider Details

I. General information

NPI: 1134838774
Provider Name (Legal Business Name): MR. ANDREW SUK WOLF AHRENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 W 7TH AVE # 560
EUGENE OR
97401-1100
US

IV. Provider business mailing address

151 W 7TH AVE # 560
EUGENE OR
97401-1100
US

V. Phone/Fax

Practice location:
  • Phone: 510-682-0089
  • Fax:
Mailing address:
  • Phone: 510-682-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberTHW000107715
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: