Basic Information
| Provider Information | |||||||||
| NPI: | 1215981832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIDENCE | ||||||||
| FirstName: | GERARDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 816 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835010816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087432511 | ||||||||
| FaxNumber: | 2087995528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 IDAHO STREET | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087437427 | ||||||||
| FaxNumber: | 2087437121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | M-8750 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | MD00042019 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.