1932169059 NPI number — MS. SUSAN PATRICIA VAWTER MN, CNM

Table of content: MS. SUSAN PATRICIA VAWTER MN, CNM (NPI 1932169059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932169059 NPI number — MS. SUSAN PATRICIA VAWTER MN, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAWTER
Provider First Name:
SUSAN
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MN, CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAWTER
Provider Other First Name:
TRISH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932169059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 E BURNSIDE ST
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97214-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-6262
Provider Business Practice Location Address Fax Number:
503-234-5437
Provider Enumeration Date:
03/23/2006

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: 367A00000X , with the licence number:  200350066NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 298493 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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