Provider Demographics
NPI:1841476017
Name:FUGELSETH, JANN M (OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:JANN
Middle Name:M
Last Name:FUGELSETH
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1404 GEKELER LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3368
Mailing Address - Country:US
Mailing Address - Phone:541-962-1025
Mailing Address - Fax:541-963-2455
Practice Address - Street 1:1404 GEKELER LN
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3368
Practice Address - Country:US
Practice Address - Phone:541-962-1025
Practice Address - Fax:541-963-2455
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0892890001Medicare NSC