Basic Information
Provider Information | |||||||||
NPI: | 1942205232 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OSWALD | ||||||||
FirstName: | MYRA | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2968 | ||||||||
Address2: |   | ||||||||
City: | ELKHART | ||||||||
State: | IN | ||||||||
PostalCode: | 465152968 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742963307 | ||||||||
FaxNumber: | 5742963309 | ||||||||
Practice Location | |||||||||
Address1: | 303 S NAPPANEE ST | ||||||||
Address2: |   | ||||||||
City: | ELKHART | ||||||||
State: | IN | ||||||||
PostalCode: | 465142066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742963307 | ||||||||
FaxNumber: | 5742963309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2005 | ||||||||
LastUpdateDate: | 03/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 28051896A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 71000022A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 200030760A | 05 | IN |   | MEDICAID |