MEDICARE: DR. DEBORAH ANN ICENOGLE MD

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	208D00000X	General Practice Physician	MD00028918	WA
2	208000000X	Pediatrics Physician	MD00028918	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831296177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBORAH ANN ICENOGLE MD

Provider Business Mailing Address
First Line	:	PO BOX 421
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-0421
Country	:	US
Telephone Number	:	509-385-0610
Fax Number	:	509-227-7070

Provider Business Practice Location Address
First Line	:	5011 W LOWELL AVE STE 100
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-8587
Country	:	US
Telephone Number	:	509-299-1958
Fax Number	:	509-299-1070

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/21/2022

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