MEDICARE: DR. DIMITRI SHCHADENKO FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95010927	CA
2	363LF0000X	Family Nurse Practitioner	67946	ID

General Provider Information

NPI Number	:	1104489343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIMITRI SHCHADENKO FNP

Provider Business Mailing Address
First Line	:	2885 NW 10TH AVE
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-3159
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2065 E 17TH ST STE A
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8042
Country	:	US
Telephone Number	:	800-640-3451
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2019
Last Update Date	:	03/20/2026

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