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General NPI Number Information
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NPI Number | 1750567129
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Entity Type | Individual
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Provider Name | ROBERT ANTHONY KIESECKER JR. DNP, FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 01/16/2008
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Last Update Date | 02/26/2020
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Provider Practice Location Address
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Address Line | 781 BLACK OAK DR STE 102
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City | MEDFORD
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State | OR
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Zip | 97504-9501
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Country | US
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Telephone | 541-789-4236
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Fax | 541-789-5965
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Provider Business Mailing Address
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Address Line | PO BOX 10880
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City | PRESCOTT
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State | AZ
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Zip | 86304-0880
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Country | US
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Telephone | 928-759-5987
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Fax | 928-458-2039
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP2889
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP60681430
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363LX0106X
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Taxonomy Name | Occupational Health Nurse Practitioner
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License Number | 201909324NP-PP
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License Number State | OR
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