Basic Information
| Provider Information | |||||||||
| NPI: | 1306265723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POULIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY # T5 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825270 | ||||||||
| FaxNumber: | 7759825288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN14274 | NV | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APRN001757 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 12675644 | 01 | CAQH | OTHER | 1306265723 | 05 | NV | MEDICAID | 2014015653 | 01 | ANCC | OTHER |