Provider Demographics
NPI:1720205578
Name:FOSMORE, NATHAN KANE (RN)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:KANE
Last Name:FOSMORE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 OAK ST SW
Mailing Address - Street 2:
Mailing Address - City:MCCHORD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:98439-1713
Mailing Address - Country:US
Mailing Address - Phone:509-869-9567
Mailing Address - Fax:
Practice Address - Street 1:US DEPT OF THE US AIRFORCE
Practice Address - Street 2:690 BARNES BLVD
Practice Address - City:MCCHORD AFB
Practice Address - State:WA
Practice Address - Zip Code:98438
Practice Address - Country:US
Practice Address - Phone:509-982-0328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00159938163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse