Healthcare Provider Details

I. General information

NPI: 1518051366
Provider Name (Legal Business Name): WAYNE L HOLLOPETER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W. NORTH STREET
GRANGEVILLE ID
83530
US

IV. Provider business mailing address

721 W. NORTH STREET
GRANGEVILLE ID
83530
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-0300
  • Fax: 208-983-9176
Mailing address:
  • Phone: 208-983-0300
  • Fax: 208-983-9176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM3216
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: