Provider Demographics
NPI:1952015471
Name:WOGAN, THEODORE CHARLES
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:CHARLES
Last Name:WOGAN
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 1:24 EMERICK ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2066
Mailing Address - Country:US
Mailing Address - Phone:541-591-5934
Mailing Address - Fax:
Practice Address - Street 1:2825 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR10003883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program