Provider Demographics
NPI:1326520719
Name:CELEDON, JOSE MANUEL (NP)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:CELEDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 E SHADY GLADE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8245
Mailing Address - Country:US
Mailing Address - Phone:208-989-6483
Mailing Address - Fax:
Practice Address - Street 1:508 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5823
Practice Address - Country:US
Practice Address - Phone:208-463-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59029363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology