MEDICARE: MR. NICHOLAS J CAMPO III PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	200950092NP	OR
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1147	AK

General Provider Information

NPI Number	:	1003071499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS J CAMPO III PMHNP

Provider Business Mailing Address
First Line	:	233 SW WILSON AVE STE 201
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-2988
Country	:	US
Telephone Number	:	541-382-8862
Fax Number	:	541-382-8928

Provider Business Practice Location Address
First Line	:	233 SW WILSON AVE STE 201
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-2988
Country	:	US
Telephone Number	:	541-382-8862
Fax Number	:	541-382-8928

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	07/15/2016

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