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General NPI Number Information
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NPI Number | 1629685235
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Entity Type | Individual
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Provider Name | MARK MITCHELL ROUBIDOUX II NP-C
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Gender | Male
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Dates
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Enumeration Date | 09/28/2020
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Last Update Date | 09/12/2025
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Provider Practice Location Address
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Address Line | 336 WARNER DR STE 4A
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City | LEWISTON
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State | ID
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Zip | 83501-4441
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Country | US
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Telephone | 208-305-3537
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Fax | 877-376-4040
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Provider Business Mailing Address
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Address Line | 320 E NEIDER AVE STE 103
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City | COEUR D ALENE
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State | ID
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Zip | 83815-6007
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Country | US
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Telephone | 208-930-4944
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Fax | 877-376-4040
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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 | 39235
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License Number State | ID
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