1922432970 NPI number — MR. NATHAN VANVICKLE CRNA

Table of content: MR. NATHAN VANVICKLE CRNA (NPI 1922432970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922432970 NPI number — MR. NATHAN VANVICKLE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANVICKLE
Provider First Name:
NATHAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922432970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6612 OPAL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99353-7961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-910-3878
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 SWIFT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99352-3514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-910-3878
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  201391621RN , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP60634596 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)