1194793083 NPI number — ANGELA DEE FERGUSON OD

Table of content: LEIGH K COOK APRN (NPI 1093156895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194793083 NPI number — ANGELA DEE FERGUSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
ANGELA
Provider Middle Name:
DEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194793083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1138
Provider Second Line Business Mailing Address:
22 W MAIN ST
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-2020
Provider Business Mailing Address Fax Number:
509-529-2115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-2020
Provider Business Practice Location Address Fax Number:
509-529-2115
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3572TX , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022886005 . This is a "REGENCE OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 140327 . This is a "DEPT OF LABOR AND INDUSTR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 257622800 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 410045308 . This is a "TRAVELERS MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: U82129 . This is a "VISION SERVICE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8886644808 . This is a "COMMUNITY HEALTH PLAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 032340000 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0323400001 . This is a "MC SUPPLY CIGNA DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2023836 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410045308 . This is a "UPPR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7753255 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3044FE . This is a "REGENCE WASHINGTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 610605300 . This is a "DEPT OF LABOR SEATTLEDFEC" identifier . This identifiers is of the category "OTHER".




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