Healthcare Provider Details

I. General information

NPI: 1750567129
Provider Name (Legal Business Name): ROBERT ANTHONY KIESECKER JR. DNP, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 BLACK OAK DR STE 102
MEDFORD OR
97504-9501
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4236
  • Fax: 541-789-5965
Mailing address:
  • Phone: 928-759-5987
  • Fax: 928-458-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP2889
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60681430
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number201909324NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: