Provider Demographics
NPI:1255498473
Name:OBSIDIAN URGENT CARE, PC
Entity Type:Organization
Organization Name:OBSIDIAN URGENT CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEONE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-962-7407
Mailing Address - Street 1:401 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1619
Mailing Address - Country:US
Mailing Address - Phone:541-962-7407
Mailing Address - Fax:541-962-7479
Practice Address - Street 1:401 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1619
Practice Address - Country:US
Practice Address - Phone:541-962-7407
Practice Address - Fax:541-962-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087000017N1 FNP-PP363LF0000X
OR200050027NP-FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR118286Medicaid
OR831550000OtherGROUP NUMBER FOR BCBS
OR931176109OtherGROUP NUMBER FOR ALL OTH
OR118286Medicaid
ORR121473Medicare PIN