Healthcare Provider Details

I. General information

NPI: 1588386676
Provider Name (Legal Business Name): KID JONATHAN CABRERA SR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 SW BOND ST
BEND OR
97702-3593
US

IV. Provider business mailing address

PO BOX 6048
BEND OR
97708-6048
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-4900
  • Fax:
Mailing address:
  • Phone: 541-382-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202210845NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: