Provider Demographics
NPI:1568415081
Name:NASSTROM, KARSON FISHER (FNP)
Entity Type:Individual
Prefix:
First Name:KARSON
Middle Name:FISHER
Last Name:NASSTROM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550009NP-PP363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR022957Medicaid
OR1407812365OtherNBMC GROUP NPI NUMBER
OR930635514OtherGROUP TAX ID FOR BILLING
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
OR0577260001Medicare NSC