Healthcare Provider Details

I. General information

NPI: 1588609176
Provider Name (Legal Business Name): NELSON ANTONIUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 02/17/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6509 HIGHWAY 2 STE 101
PRIEST RIVER ID
83856-6609
US

IV. Provider business mailing address

PO BOX 2160
SANDPOINT ID
83864-0908
US

V. Phone/Fax

Practice location:
  • Phone: 208-448-2321
  • Fax: 208-448-1317
Mailing address:
  • Phone: 208-263-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-13097
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00040823
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: