Provider Demographics
NPI:1336650357
Name:CHAKO, WONDMIMU EDAO
Entity Type:Individual
Prefix:
First Name:WONDMIMU
Middle Name:EDAO
Last Name:CHAKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 SE 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2731
Mailing Address - Country:US
Mailing Address - Phone:971-255-0029
Mailing Address - Fax:
Practice Address - Street 1:3708 SE 144TH AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236
Practice Address - Country:US
Practice Address - Phone:971-255-0029
Practice Address - Fax:503-762-9080
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200241818RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200241818RNOtherOBN