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1114542065 NPI number — GARY JOHN CLINTON MERSEREAU SR. BSN, RN

NPI Number: 1114542065
Health Care Provider/Practitioner: GARY JOHN CLINTON MERSEREAU SR. BSN, RN

Information about “1114542065” NPI (GARY JOHN CLINTON MERSEREAU SR. BSN, RN) exists in 1114542065 in HTML format HTML  |  1114542065 in plain Text format TXT  |  1114542065 in PDF (Portable Document Format) PDF  |  1114542065 in an XML format XML  formats.

NPI Number : 1114542065 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1114542065",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MERSEREAU",
    "FirstName": "GARY",
    "MiddleName": "JOHN CLINTON",
    "NamePrefix": "MR.",
    "NameSuffix": "SR.",
    "Credential": "BSN, RN",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "815 WAYNE DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "CENTRALIA",
    "MailingAddressStateName": "WA",
    "MailingAddressPostalCode": "98531-9024",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "914 S SCHEUBER RD",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "CENTRALIA",
    "PracticeLocationAddressStateName": "WA",
    "PracticeLocationAddressPostalCode": "98531-9027",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "360-330-8785",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "06/16/2020",
    "LastUpdateDate": "06/16/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "163WE0003X",
        "TaxonomyName": "Emergency Registered Nurse",
        "LicenseNumber": "RN60383846",
        "LicenseNumberStateCode": "WA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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