Healthcare Provider Details

I. General information

NPI: 1265849350
Provider Name (Legal Business Name): LAURA MATJASICH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 MADRONA ST N BLDG 1200
TWIN FALLS ID
83301-8334
US

IV. Provider business mailing address

1505 MADRONA ST N BLDG 1200
TWIN FALLS ID
83301-8334
US

V. Phone/Fax

Practice location:
  • Phone: 208-886-0774
  • Fax:
Mailing address:
  • Phone: 208-886-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5673235-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number55385
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: