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1205793395 NPI number — JEREMY GLENN NUGENT CM60686561

NPI Number: 1205793395
Health Care Provider/Practitioner: JEREMY GLENN NUGENT CM60686561

Information about “1205793395” NPI (JEREMY GLENN NUGENT CM60686561) exists in 1205793395 in HTML format HTML  |  1205793395 in plain Text format TXT  |  1205793395 in PDF (Portable Document Format) PDF  |  1205793395 in an XML format XML  formats.

NPI Number : 1205793395 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1205793395",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "NUGENT",
    "FirstName": "JEREMY",
    "MiddleName": "GLENN",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "CM60686561",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "NUGENT",
    "OtherFirstName": "JAY",
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": "CM60686561",
    "OtherLastNameTypeCode": "5",
    "FirstLineMailingAddress": "10503 CREEK ST SE UNIT 115",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "YELM",
    "MailingAddressStateName": "WA",
    "MailingAddressPostalCode": "98597-8678",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "360-623-8056",
    "MailingAddressFaxNumber": "360-623-1072",
    "FirstLinePracticeLocationAddress": "3510 STEELHAMMER DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "CENTRALIA",
    "PracticeLocationAddressStateName": "WA",
    "PracticeLocationAddressPostalCode": "98531-1532",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "360-623-8056",
    "PracticeLocationAddressFaxNumber": "360-623-1072",
    "EnumerationDate": "01/08/2026",
    "LastUpdateDate": "01/08/2026",
    "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": "207PE0004X",
        "TaxonomyName": "Emergency Medical Services (Emergency Medicine) Physician",
        "LicenseNumber": "CM6066561",
        "LicenseNumberStateCode": "WA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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