MEDICARE: MR. RICHARD ANDREW DOMITER RN

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	163W00000X	Registered Nurse	127665-30	WI
2	163WC0400X	Case Management Registered Nurse	127665-30	WI
3	163WH0200X	Home Health Registered Nurse	127665-30	WI

General Provider Information

NPI Number	:	1780013094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD ANDREW DOMITER RN

Provider Business Mailing Address
First Line	:	1804 FAIRVIEW ST
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54901-2404
Country	:	US
Telephone Number	:	920-235-6205
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 FAIRVIEW ST
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54901-2404
Country	:	US
Telephone Number	:	920-235-6205
Fax Number	:

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

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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