Basic Information
| Provider Information | |||||||||
| NPI: | 1255459558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 N SYRINGA ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622600 | ||||||||
| FaxNumber: | 2082622700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | M-9075 | ID | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207P00000X | M-9075 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083A0100X | M-9075 | ID | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1255459558 | 05 | ID | MEDICAID |