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NPI Code Detail

MEDICARE: DEO M PEPPERSACK NP

MEDICARE: DEO M PEPPERSACK NP
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
1163W00000XRegistered NurseNP656AID
2363LF0000XFamily Nurse PractitionerNP656AID
3363LP0808XPsychiatric/Mental Health Nurse PractitionerNP656AID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3NP191OTHERIDBLUE CROSS

General Provider Information

NPI Number : 1770538811
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEO M PEPPERSACK NP
Provider Business Mailing Address
First Line : 217 W. GEORGIA AVE. STE 120
Second Line :
City : NAMPA
State : ID
Zip : 83686-2856
Country : US
Telephone Number : 208-498-1760
Fax Number : 208-498-1769
Provider Business Practice Location Address
First Line : 217 W GEORGIA AVE STE 120
Second Line :
City : NAMPA
State : ID
Zip : 83686-6812
Country : US
Telephone Number : 208-498-1760
Fax Number : 208-498-1761
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2006
Last Update Date : 03/18/2016

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Directions to “ DEO M PEPPERSACK NP” Practice Location

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