Provider Demographics
NPI:1417067398
Name:MCINTOSH, TRISHA ELIZABETH (ACNP)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:ELIZABETH
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:ELIZABETH
Other - Last Name:BRONDYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1236 E RUSHOLME ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2473
Mailing Address - Country:US
Mailing Address - Phone:563-324-2992
Mailing Address - Fax:563-888-0499
Practice Address - Street 1:1236 E RUSHOLME ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2473
Practice Address - Country:US
Practice Address - Phone:563-324-2992
Practice Address - Fax:563-888-0499
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAL087413363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA05286OtherWELLMARK BCBS OF IOWA
P00282085OtherRAILROAD MEDICARE
IA0487967Medicaid
IAQ55755Medicare UPIN
IAI16394Medicare PIN