Provider Demographics
NPI:1932654118
Name:NAKKA, SUJAY
Entity Type:Individual
Prefix:
First Name:SUJAY
Middle Name:
Last Name:NAKKA
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 1:706 MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2844
Mailing Address - Country:US
Mailing Address - Phone:503-354-2523
Mailing Address - Fax:503-354-5116
Practice Address - Street 1:706 MEADOW AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2844
Practice Address - Country:US
Practice Address - Phone:503-354-2523
Practice Address - Fax:503-354-5116
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR500697789171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500697789OtherOREGON HEALTH AUTHORITY