Provider Demographics
NPI:1104539634
Name:COOVER, NGAMETUA VARU (LMT)
Entity type:Individual
Prefix:
First Name:NGAMETUA
Middle Name:VARU
Last Name:COOVER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 NE 124TH AVE APT D48
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1603
Mailing Address - Country:US
Mailing Address - Phone:503-915-2619
Mailing Address - Fax:
Practice Address - Street 1:9120 NE VANCOUVER MALL LOOP STE 120
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6354
Practice Address - Country:US
Practice Address - Phone:564-219-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61323063225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist