1932247665 NPI number — JUDY A METELKO CNS,ARNP

Table of content: JUDY A METELKO CNS,ARNP (NPI 1932247665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932247665 NPI number — JUDY A METELKO CNS,ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METELKO
Provider First Name:
JUDY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNS,ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932247665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-2431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-743-2511
Provider Business Mailing Address Fax Number:
208-799-5554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-2511
Provider Business Practice Location Address Fax Number:
208-799-5554
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SP0809X , with the licence number:  CNS-1A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9627472 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HBUR5 . This is a "IDAHO BLUE CROSS IND" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805366200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8C576 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 10017766 . This is a "REGENCE OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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