Provider Demographics
NPI:1508918236
Name:DODGE, ELMER G JR (FNP)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:G
Last Name:DODGE
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44267
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0267
Mailing Address - Country:US
Mailing Address - Phone:208-286-0666
Mailing Address - Fax:208-286-0565
Practice Address - Street 1:9858 W STATE ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5210
Practice Address - Country:US
Practice Address - Phone:208-286-0666
Practice Address - Fax:208-286-0565
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP534A163WG0000X
IDNP-534A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNPQP7OtherBLUE CROSS OF IDAHO
ID000010150031OtherREGENCE BLUE SHIELD OF ID
ID806045400Medicaid