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General NPI Number Information
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NPI Number | 1659149086
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Entity Type | Individual
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Provider Name | KENNETH JAMES GUNDERSON FNP-C
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Gender | Male
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Dates
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Enumeration Date | 12/14/2023
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Last Update Date | 02/21/2024
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Provider Practice Location Address
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Address Line | 1950 SAINT CLAIR RD
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6306
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Country | US
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Telephone | 208-569-8249
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Fax |
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Provider Business Mailing Address
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Address Line | 1950 SAINT CLAIR RD
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6306
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Country | US
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Telephone | 208-569-8249
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F12230320
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License Number State | ID
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