Provider Demographics
NPI:1306129614
Name:NEWSOME, WANDA CAROL (CNP)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:CAROL
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0579
Mailing Address - Country:US
Mailing Address - Phone:541-766-0174
Mailing Address - Fax:541-766-6164
Practice Address - Street 1:100 MULLINS DR STE A1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2868
Practice Address - Country:US
Practice Address - Phone:541-766-0200
Practice Address - Fax:541-766-6618
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201908923NP-PP363L00000X
MSR870610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01341901OtherRAILROAD MEDICARE
MS01133325Medicaid
MS9876741OtherAETNA
MS01133325Medicaid