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NPI Code Detail

MEDICARE: ADAM JOSEPH THETFORD APRN, PMHNP

MEDICARE: ADAM JOSEPH THETFORD APRN, PMHNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner5981802ID

General Provider Information

NPI Number : 1316884091
Entity Type Code : Individual
Provider Name (Legal Business Name) : ADAM JOSEPH THETFORD APRN, PMHNP
Provider Business Mailing Address
First Line : 3100 CHANNING WAY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7533
Country : US
Telephone Number : 208-529-6111
Fax Number :
Provider Business Practice Location Address
First Line : 3100 CHANNING WAY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7533
Country : US
Telephone Number : 208-529-6111
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2026
Last Update Date : 05/20/2026

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