Basic Information
| Provider Information | |||||||||
| NPI: | 1366890444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STATON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | PEARCE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2413 CONGER AVE NW UNIT B | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985024507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605397365 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412650581 | ||||||||
| FaxNumber: | 5415746252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2016 | ||||||||
| LastUpdateDate: | 05/30/2016 | ||||||||
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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 | 201603348RN | OR | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 201603348RN | 01 | OR | RN | OTHER |