Healthcare Provider Details

I. General information

NPI: 1962311696
Provider Name (Legal Business Name): JOSHUA MACKENZIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

IV. Provider business mailing address

382 PARTRIDGE LN
REXBURG ID
83440-3593
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-4100
  • Fax:
Mailing address:
  • Phone: 208-243-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number6981608
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: