MEDICARE: NORTHSTAR HEALTHCARE LLC

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
1	363L00000X	Nurse Practitioner
2	363L00000X	Nurse Practitioner	NP386A	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DC1808	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598849051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSTAR HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	1995 E 17TH ST
Second Line	:	STE 2
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6493
Country	:	US
Telephone Number	:	208-529-2352
Fax Number	:	208-528-3332

Provider Business Practice Location Address
First Line	:	1995 E 17TH ST
Second Line	:	STE 2
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6493
Country	:	US
Telephone Number	:	208-529-2352
Fax Number	:	208-528-3332

Authorized Official
Title or Position	:	OWNER/FNPC
Name	:	LAURA J. MASON
Credential	:	FNPC
Telephone Number	:	208-529-2352

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	02/03/2012

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Directions to “NORTHSTAR HEALTHCARE LLC ” Practice Location

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