Provider Demographics
NPI:1720851637
Name:MUCYO, CLEMENT
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:
Last Name:MUCYO
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 1:80 SE MADISON ST STE 242
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4527
Mailing Address - Country:US
Mailing Address - Phone:240-923-0453
Mailing Address - Fax:
Practice Address - Street 1:80 SE MADISON ST STE 242
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4527
Practice Address - Country:US
Practice Address - Phone:240-923-0453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist