Basic Information
| Provider Information | |||||||||
| NPI: | 1831183326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSELAND | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MSN, RN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSELAND | ||||||||
| OtherFirstName: | TOM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSN, RN, FNP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4803 ELKRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WEED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960949424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097696112 | ||||||||
| FaxNumber: | 2097200139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 NW STEWART PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | RN 409980 | CA | N | Nursing Service Providers | Registered Nurse | General Practice | 363LF0000X | 201811353 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | NP9245 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201811353RN | 01 | OR | OREGON RN LICENSE | OTHER | 500759209 | 05 | OR | MEDICAID | MR0488913 | 01 | CA | DEA | OTHER | RN049980 | 01 | CA | CA RN LICENSE | OTHER | 201811353NP-PP | 01 | OR | OREGON FNP LICENS | OTHER | NP9245 | 01 | CA | CA FNP LICENSE | OTHER | XR0488913 | 01 | CA | DEA X-WAIVER LICENSE | OTHER | NP 9245 | 01 | CA | BRN-CALIF FNP LICENSE | OTHER |