Provider Demographics
NPI:1184209603
Name:CHUPP, PEGGY ANN
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:CHUPP
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 1:603 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97114-9782
Mailing Address - Country:US
Mailing Address - Phone:503-437-4255
Mailing Address - Fax:
Practice Address - Street 1:377 NW JASPER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1279
Practice Address - Country:US
Practice Address - Phone:503-623-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7387208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation