Provider Demographics
NPI:1164100830
Name:MCCOY, AJAMU BILL (MA)
Entity Type:Individual
Prefix:
First Name:AJAMU
Middle Name:BILL
Last Name:MCCOY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:AJ
Other - Middle Name:
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-0445
Mailing Address - Fax:
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide