Healthcare Provider Details

I. General information

NPI: 1558075903
Provider Name (Legal Business Name): SUSAN W WANGUGI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
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: 253-929-4061
  • Fax:
Mailing address:
  • Phone: 253-929-4061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberB202304
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: