Healthcare Provider Details

I. General information

NPI: 1588654628
Provider Name (Legal Business Name): GLADE SOUTHAM NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BYU - IDAHO 100 SHC
REXBURG ID
83460-2010
US

IV. Provider business mailing address

BYU - IDAHO NURSING DEPARTMENT 117C CLARKE
REXBURG ID
83460-0620
US

V. Phone/Fax

Practice location:
  • Phone: 208-496-1300
  • Fax:
Mailing address:
  • Phone: 208-496-1385
  • Fax: 208-496-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP - 747A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: