Individual
NOMIN PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
1003 E MAIN ST STE 104, MEDFORD, OR 97504-7140
(541) 779-1282
Mailing address
1003 E MAIN ST STE 104, MEDFORD, OR 97504-7140
(541) 292-7639
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
10026206
OR
363LF0000X
Family Nurse Practitioner
Primary
10026206
OR
Other
Enumeration date
05/14/2024
Last updated
10/09/2024
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