=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205793395
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY GLENN NUGENT CM60686561
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2026
-----------------------------------------------------
Last Update Date | 01/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3510 STEELHAMMER DR
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-623-8056
-----------------------------------------------------
Fax | 360-623-1072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10503 CREEK ST SE UNIT 115
-----------------------------------------------------
City | YELM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98597-8678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-623-8056
-----------------------------------------------------
Fax | 360-623-1072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | CM6066561
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------