=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073469763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ADAM MARION LPN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2026
-----------------------------------------------------
Last Update Date | 03/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2325 CORONADO ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-557-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 S 5TH W APT 2203
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-5219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 79130
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------