Basic Information
| Provider Information | |||||||||
| NPI: | 1740326990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KUNA FAMILY MEDICAL CLINIC, P. A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | KUNA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836340068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089225130 | ||||||||
| FaxNumber: | 2089225132 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 E WYTHE CREEK CT STE 103 | ||||||||
| Address2: | |||||||||
| City: | KUNA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836345005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089225130 | ||||||||
| FaxNumber: | 2089225132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | MYRNA | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2089225130 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP193A | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 804073900 | 05 | ID | MEDICAID |