Provider Demographics
NPI:1235306911
Name:SKUCAS, AMY ROSEANNE (DO00002207)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ROSEANNE
Last Name:SKUCAS
Suffix:
Gender:F
Credentials:DO00002207
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ROSEANNE
Other - Last Name:LUGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:YACOLT
Mailing Address - State:WA
Mailing Address - Zip Code:98675
Mailing Address - Country:US
Mailing Address - Phone:360-903-9717
Mailing Address - Fax:
Practice Address - Street 1:500 MULTNOMAH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-571-5675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00002207156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADO00002207OtherWASHINGTON STATE LICENSED DISPENSING OPTICIAN