Provider Demographics
NPI:1437381209
Name:MORGAN, MARY M (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:MORGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1160 WOODSAGE AVENUE
Mailing Address - Street 2:BLDG A
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-906-1231
Mailing Address - Fax:208-906-1232
Practice Address - Street 1:1660 WOODSAGE AVE, BLDG A
Practice Address - Street 2:
Practice Address - City:MERRIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-906-1231
Practice Address - Fax:208-906-1232
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID20407A364SF0001X
IDNP-937A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1437381209Medicaid
ID808586900Medicaid
ID20004259Medicare PIN
ID20004260Medicare PIN
ID1437381209Medicaid
ID20004262Medicare PIN
ID808586900Medicaid