Provider Demographics
NPI:1699787655
Name:DUTSON, MICAL THOMAS (NP)
Entity type:Individual
Prefix:
First Name:MICAL
Middle Name:THOMAS
Last Name:DUTSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:WILBUR
Mailing Address - State:OR
Mailing Address - Zip Code:97494-0716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR094006089N1 FNP-PP282N00000X
OR163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered282N00000XHospitalsGeneral Acute Care Hospital
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice