Healthcare Provider Details

I. General information

NPI: 1346674983
Provider Name (Legal Business Name): STEPHEN TRADER ELLIOTT JR. REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2013
Last Update Date: 08/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KAMC, NGH, MC 1, BUILDING 12, APT. 8 ER MAIL COSE 6338
JEDDAH MAKKAH
21423
SA

IV. Provider business mailing address

KAMC, NGH, MC 1, BUILDING 12, APT. 8 PO BOX 9515, ER MAIL COSE 6338
JEDDAH MAKKAH
21423
SA

V. Phone/Fax

Practice location:
  • Phone: 50-798-6510
  • Fax:
Mailing address:
  • Phone: 50-798-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number617505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: