Provider Demographics
NPI:1063446094
Name:KUPCHOCK, SALLY (NP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:KUPCHOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7003
Mailing Address - Country:US
Mailing Address - Phone:208-227-6753
Mailing Address - Fax:
Practice Address - Street 1:1182 E 21ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7003
Practice Address - Country:US
Practice Address - Phone:208-227-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP737A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNPXT3OtherBLUE CROSS ID
Q16891Medicare UPIN
IDNPXT3OtherBLUE CROSS ID