Provider Demographics
NPI:1518914373
Name:MAYUGA, ENRIQUETA (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUETA
Middle Name:
Last Name:MAYUGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 W PARK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5270
Mailing Address - Country:US
Mailing Address - Phone:509-547-5261
Mailing Address - Fax:509-547-5261
Practice Address - Street 1:531 W PARK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301
Practice Address - Country:US
Practice Address - Phone:509-547-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010863207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023654Medicaid
A07306Medicare UPIN
WAG000300969Medicare PIN