Healthcare Provider Details

I. General information

NPI: 1659169415
Provider Name (Legal Business Name): PETER MWANGI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 NW RIVERVIEW AVE
GRESHAM OR
97030-4918
US

IV. Provider business mailing address

890 NW RIVERVIEW AVE
GRESHAM OR
97030-4918
US

V. Phone/Fax

Practice location:
  • Phone: 508-202-6604
  • Fax:
Mailing address:
  • Phone: 508-202-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number202103094LPN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: