Healthcare Provider Details

I. General information

NPI: 1063445385
Provider Name (Legal Business Name): JANE A FORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 SIXTH ST
LEWISTON ID
83501
US

IV. Provider business mailing address

1119 HIGHLAND AVE SUITE 7
CLARKSTON WA
99403-2836
US

V. Phone/Fax

Practice location:
  • Phone: 208-750-7445
  • Fax:
Mailing address:
  • Phone: 509-758-1119
  • Fax: 509-758-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00036657
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-4493
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: