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General NPI Number Information
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NPI Number | 1902836802
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Entity Type | Individual
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Provider Name | WILLIAM MARK IMUS JR. FNP
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Gender | Male
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 07/08/2009
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Provider Practice Location Address
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Address Line | 610 NW 2ND ST
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City | GRANGEVILLE
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State | ID
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Zip | 83530-1244
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Country | US
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Telephone | 208-983-5120
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Fax | 208-983-5404
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Provider Business Mailing Address
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Address Line | 610 NW 2ND ST
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City | GRANGEVILLE
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State | ID
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Zip | 83530-1244
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Country | US
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Telephone | 208-983-5120
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Fax | 208-983-5404
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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 | NP57A
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License Number State | ID
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