MEDICARE: MAVERICK MITTON FNP-C

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	5671698	ID

General Provider Information

NPI Number	:	1396602249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAVERICK MITTON FNP-C

Provider Business Mailing Address
First Line	:	1550 CAYUSE CREEK DR
Second Line	:
City	:	KIMBERLY
State	:	ID
Zip	:	83341-5126
Country	:	US
Telephone Number	:	808-489-6202
Fax Number	:

Provider Business Practice Location Address
First Line	:	775 POLE LINE RD
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3036
Country	:	US
Telephone Number	:	208-814-1000
Fax Number	:

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

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	02/09/2026

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