Healthcare Provider Details

I. General information

NPI: 1396509311
Provider Name (Legal Business Name): MATTHEW AARON DOUGLASS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 17TH ST
IDAHO FALLS ID
83404-6126
US

IV. Provider business mailing address

1248 E 17TH ST
IDAHO FALLS ID
83404-6126
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax: 208-528-2945
Mailing address:
  • Phone: 208-542-1026
  • Fax: 208-528-2945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number59035
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-78862
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: