MEDICARE: MR. JOHN MERCER SMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1710266119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MERCER SMT

Provider Business Mailing Address
First Line	:	1051 1ST ST E APT 111
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3038
Country	:	US
Telephone Number	:	701-429-7992
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 1ST ST E APT 111
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3038
Country	:	US
Telephone Number	:	701-429-7992
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	08/16/2011

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