Provider Demographics
NPI:1437978038
Name:WACHUKA, ANTONY MBERERI (MD)
Entity type:Individual
Prefix:MR
First Name:ANTONY
Middle Name:MBERERI
Last Name:WACHUKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SW HILLVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-3906
Mailing Address - Country:US
Mailing Address - Phone:541-452-1033
Mailing Address - Fax:541-452-1033
Practice Address - Street 1:1320 SW HILLVIEW AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-3906
Practice Address - Country:US
Practice Address - Phone:541-452-1033
Practice Address - Fax:541-452-1033
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR529871372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty