Provider Demographics
NPI:1063872489
Name:BLUE LAKES MEDICINE PA
Entity type:Organization
Organization Name:BLUE LAKES MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:RUSTY
Authorized Official - Last Name:ARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, DC
Authorized Official - Phone:208-734-9531
Mailing Address - Street 1:1122 EASTLAND DR N
Mailing Address - Street 2:STE 2
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8444
Mailing Address - Country:US
Mailing Address - Phone:208-734-9531
Mailing Address - Fax:208-733-6969
Practice Address - Street 1:1122 EASTLAND DR N
Practice Address - Street 2:STE 2
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-8444
Practice Address - Country:US
Practice Address - Phone:208-734-9531
Practice Address - Fax:208-733-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1688A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374328OtherMEDICARE PTAN