Healthcare Provider Details

I. General information

NPI: 1568200525
Provider Name (Legal Business Name): REBECCA WAMBUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 N INTERSTATE AVE
PORTLAND OR
97227-1108
US

IV. Provider business mailing address

17318 SW JAY ST APT 306
BEAVERTON OR
97003-7649
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number0019256
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: