Healthcare Provider Details

I. General information

NPI: 1396947065
Provider Name (Legal Business Name): SUSAN RUTH EKI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN RUTH SAGAWA-EKI PMHNP

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 503C
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

644 SW WALTERS DR
GRESHAM OR
97080-9351
US

V. Phone/Fax

Practice location:
  • Phone: 971-888-2014
  • Fax: 971-206-6387
Mailing address:
  • Phone: 971-888-2014
  • Fax: 971-206-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number077037817N2
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number077037817N2
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200250006NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: