Provider Demographics
NPI:1811537012
Name:MOURITSEN, THOMAS LAMAR
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LAMAR
Last Name:MOURITSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 4TH STREET 16A
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 E HASKELL ST
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-3247
Practice Address - Country:US
Practice Address - Phone:775-623-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV826747367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered