Basic Information
| Provider Information | |||||||||
| NPI: | 1417923632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUKE | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664547 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 200050072NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1619915113 | 01 | OR | WATERFALL CLINIC -NPI | OTHER | CB3544 | 01 | OR | TRAV RR GROUP NUMBER | OTHER | P00412791 | 01 | OR | TRAV RR PTAN NUMBER | OTHER | R0000WFBTV | 01 | OR | GROUP PIN NUMBER | OTHER | 381902 | 01 | OR | WATERFALL CLINIC MEDICARE/OSCAR | OTHER | 930635514 | 01 | OR | GROUP TAX ID | OTHER | 291671 | 05 | OR | MEDICAID | 1407812365 | 01 | OR | NBMC NPI NUMBER-GROUP | OTHER | 213342 | 01 | OR | WATERFALL CLINIC DMAP | OTHER |