Provider Demographics
NPI:1366890444
Name:STATON, JERRY PEARCE (RN)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:PEARCE
Last Name:STATON
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 1:2413 CONGER AVE NW UNIT B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4507
Mailing Address - Country:US
Mailing Address - Phone:360-539-7365
Mailing Address - Fax:
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-0581
Practice Address - Fax:541-574-6252
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201603348RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201603348RNOtherRN