Healthcare Provider Details

I. General information

NPI: 1912095563
Provider Name (Legal Business Name): JAN SUND FNP,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 SHOUP AVE W STE C
TWIN FALLS ID
83301-5043
US

IV. Provider business mailing address

496 SHOUP AVE W STE C
TWIN FALLS ID
83301-5043
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-6677
  • Fax: 208-733-6674
Mailing address:
  • Phone: 208-733-6677
  • Fax: 208-733-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberNP282-A
License Number StateID

VIII. Authorized Official

Name: JAN A SUND
Title or Position: PRESIDENT
Credential: FNP.PC
Phone: 208-733-6677