MEDICARE: GEM FAMILY PRACTICE

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	363L00000X	Nurse Practitioner	NP238A	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010017986	OTHER	ID	REGENCE BLUE SHIELD
2	NP190	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1407919749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEM FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	1108 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3455
Fax Number	:	208-365-3422

Provider Business Practice Location Address
First Line	:	1108 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3455
Fax Number	:	208-365-3422

Authorized Official
Title or Position	:	FNP
Name	:	MS. DEBORAH A CASDORPH
Credential	:	FNP
Telephone Number	:	208-365-3455

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/22/2020

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Directions to “GEM FAMILY PRACTICE ” Practice Location

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