MEDICARE: MRS. YVONNE EGENDOERFER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	RPH 0011349	OR

General Provider Information

NPI Number	:	1558758169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. YVONNE EGENDOERFER

Provider Business Mailing Address
First Line	:	404 N MAIN ST
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-9632
Country	:	US
Telephone Number	:	541-535-1561
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 N MAIN ST
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-9632
Country	:	US
Telephone Number	:	541-535-1561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	04/21/2015

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