Healthcare Provider Details

I. General information

NPI: 1639726334
Provider Name (Legal Business Name): MATTHEW SCOTT KINGHORN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 02/11/2022
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A205
IDAHO FALLS ID
83404-7586
US

IV. Provider business mailing address

PO BOX 277381
ATLANTA GA
30384-7381
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4580
  • Fax: 208-535-4520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62114
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: