Provider Demographics
NPI:1902836802
Name:IMUS, WILLIAM MARK JR (FNP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:IMUS
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1244
Mailing Address - Country:US
Mailing Address - Phone:208-983-5120
Mailing Address - Fax:208-983-5404
Practice Address - Street 1:610 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1244
Practice Address - Country:US
Practice Address - Phone:208-983-5120
Practice Address - Fax:208-983-5404
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP57A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804251600Medicaid
IDNPWD6OtherBLUE CROSS OF IDAHO
ID000010152061OtherREGENCE BLUE SHIELD
ID804251600Medicaid
ID1341014Medicare ID - Type Unspecified