Basic Information
| Provider Information | |||||||||
| NPI: | 1598956252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EKERSON | ||||||||
| FirstName: | PRISCILLA | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAW | ||||||||
| OtherFirstName: | PRISCILLA | ||||||||
| OtherMiddleName: | NOEL | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 471-215 SINGLE TREE LN | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961305053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082301905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302522000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 574160 | CA | N | Nursing Service Providers | Registered Nurse | 367500000X | AP60565020 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 080296 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.