Provider Demographics
NPI:1407919749
Name:GEM FAMILY PRACTICE
Entity Type:Organization
Organization Name:GEM FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASDORPH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:208-365-3455
Mailing Address - Street 1:1108 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3535
Mailing Address - Country:US
Mailing Address - Phone:208-365-3455
Mailing Address - Fax:208-365-3422
Practice Address - Street 1:1108 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3535
Practice Address - Country:US
Practice Address - Phone:208-365-3455
Practice Address - Fax:208-365-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP238A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017986OtherREGENCE BLUE SHIELD
IDNP190OtherBLUE CROSS
ID1342055Medicare ID - Type UnspecifiedMEDICARE BILLING NUMBER
ID000010017986OtherREGENCE BLUE SHIELD