Basic Information
| Provider Information | |||||||||
| NPI: | 1811537012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOURITSEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LAMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 E 4TH STREET 16A | ||||||||
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| City: | WINNEMUCCA | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89445 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 E HASKELL ST | ||||||||
| Address2: | |||||||||
| City: | WINNEMUCCA | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894453247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756235222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 826747 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.