Provider Demographics
NPI:1104802099
Name:UGADDAN, MARY ANDREA GO (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARY ANDREA
Middle Name:GO
Last Name:UGADDAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-2420
Mailing Address - Country:US
Mailing Address - Phone:908-887-5298
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-5001
Practice Address - Country:US
Practice Address - Phone:253-968-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY565202163W00000X
390200000X
WA70027516363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN