Provider Demographics
NPI:1528351228
Name:TUMBAGA, EVAN KUUIPO
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:KUUIPO
Last Name:TUMBAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11312 KENAI SPUR HWY
Mailing Address - Street 2:SUITE 63
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7754
Mailing Address - Country:US
Mailing Address - Phone:907-335-2008
Mailing Address - Fax:907-335-4673
Practice Address - Street 1:11312 KENAI SPUR HWY
Practice Address - Street 2:SUITE 63
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7754
Practice Address - Country:US
Practice Address - Phone:907-335-2008
Practice Address - Fax:907-335-4673
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK550871179251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management