=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811537012
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS LAMAR MOURITSEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 E HASKELL ST
-----------------------------------------------------
City | WINNEMUCCA
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89445-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-623-5222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190930
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83719-0930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-5170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 202100196CRNA
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 826747
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------