Healthcare Provider Details

I. General information

NPI: 1760435820
Provider Name (Legal Business Name): DOUGLAS A NASSTROM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 THOMPSON RD
COOS BAY OR
97420-2125
US

IV. Provider business mailing address

PO BOX 349 1860 VIRGINIA AVENUE, STE 9
NORTH BEND OR
97459-0106
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-8020
  • Fax:
Mailing address:
  • Phone: 541-756-2070
  • Fax: 541-756-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: