=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851103063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AETHERIUS MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 N MAIN ST
-----------------------------------------------------
City | NOBLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73068-9574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-339-5261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 N MAIN ST
-----------------------------------------------------
City | NOBLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73068-9574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-300-1476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER - FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. KRYSTEN MESCAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-300-1476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------