Healthcare Provider Details

I. General information

NPI: 1194645473
Provider Name (Legal Business Name): SUSANA MCALLASTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 C STREET SUITE 200
INDEPENDENCE OR
97351
US

IV. Provider business mailing address

17935 ROBB MILL RD
DALLAS OR
97338-9111
US

V. Phone/Fax

Practice location:
  • Phone: 310-505-2182
  • Fax:
Mailing address:
  • Phone: 310-505-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10062892
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: