Healthcare Provider Details

I. General information

NPI: 1871730127
Provider Name (Legal Business Name): LWAFP, PC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 E MAIN ST
ROGUE RIVER OR
97537-9416
US

IV. Provider business mailing address

216 E MAIN ST
ROGUE RIVER OR
97537-9416
US

V. Phone/Fax

Practice location:
  • Phone: 541-582-8899
  • Fax:
Mailing address:
  • Phone: 541-582-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number200850056NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP200250078
License Number StateOR

VIII. Authorized Official

Name: LINDA M PICKER
Title or Position: OWNER
Credential: ANP
Phone: 541-474-9400