Provider Demographics
NPI:1780013094
Name:DOMITER, RICHARD ANDREW (RN)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ANDREW
Last Name:DOMITER
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 1:1804 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2404
Mailing Address - Country:US
Mailing Address - Phone:920-235-6205
Mailing Address - Fax:
Practice Address - Street 1:1804 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2404
Practice Address - Country:US
Practice Address - Phone:920-235-6205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127665-30163W00000X, 163WC0400X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health