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General NPI Number Information
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NPI Number | 1457792277
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Entity Type | Individual
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Provider Name | RICHARD M MCCONKIE JR. NP-C
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Gender | Male
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Dates
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Enumeration Date | 07/09/2013
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 4740 N PENNGROVE WAY
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City | MERIDIAN
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State | ID
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Zip | 83646-7443
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Country | US
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Telephone | 208-514-0203
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 277976
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City | ATLANTA
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State | GA
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Zip | 30384-7976
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | NP 1302 A
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License Number State | ID
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