Provider Demographics
NPI:1497719256
Name:MAYUGA, HENRIETTA LORENA (MD)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:LORENA
Last Name:MAYUGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:H
Other - Middle Name:LORENA
Other - Last Name:MAYUGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7131 W DESCHUTES AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7801
Mailing Address - Country:US
Mailing Address - Phone:509-222-1260
Mailing Address - Fax:509-222-1264
Practice Address - Street 1:7131 W DESCHUTES AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-222-1260
Practice Address - Fax:509-222-1264
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035419207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA319211600OtherMEDICARE GROUP #
WA8211757Medicaid
WA319211600OtherMEDICARE GROUP #
G83843Medicare UPIN