Provider Demographics
NPI:1043931637
Name:FREMONT MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:FREMONT MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDMUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-624-2969
Mailing Address - Street 1:30 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-2113
Mailing Address - Country:US
Mailing Address - Phone:208-624-2969
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-2113
Practice Address - Country:US
Practice Address - Phone:208-624-2969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center