Provider Demographics
NPI:1558758169
Name:EGENDOERFER, YVONNE
Entity Type:Individual
Prefix:MRS
First Name:YVONNE
Middle Name:
Last Name:EGENDOERFER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BENJAIM
Other - Middle Name:R
Other - Last Name:EGENDOERFER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:404 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-9632
Mailing Address - Country:US
Mailing Address - Phone:541-535-1561
Mailing Address - Fax:
Practice Address - Street 1:404 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9632
Practice Address - Country:US
Practice Address - Phone:541-535-1561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH 0011349173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107150Medicare PIN