Provider Demographics
NPI:1477961308
Name:WISHAM, AUDRA LUZ KATHLEENA (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA LUZ
Middle Name:KATHLEENA
Last Name:WISHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AUDRA LUZ
Other - Middle Name:KATHLEENA
Other - Last Name:ALMEYDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2847
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 SW ABBEY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4820
Practice Address - Country:US
Practice Address - Phone:541-265-2244
Practice Address - Fax:541-574-1838
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD182496207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500729523Medicaid