Provider Demographics
NPI:1790241065
Name:AUTUMN D MERCER AGNP-C LLC
Entity Type:Organization
Organization Name:AUTUMN D MERCER AGNP-C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-309-8026
Mailing Address - Street 1:620 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9659
Mailing Address - Country:US
Mailing Address - Phone:503-309-8026
Mailing Address - Fax:541-291-9819
Practice Address - Street 1:620 N 5TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9659
Practice Address - Country:US
Practice Address - Phone:503-309-8026
Practice Address - Fax:541-291-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500733407Medicaid