Provider Demographics
NPI:1518507086
Name:PUSTYNOVICH, VADIM P (FNP-C)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:P
Last Name:PUSTYNOVICH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-3640
Mailing Address - Fax:208-625-3645
Practice Address - Street 1:700 W IRONWOOD DR STE 120
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4405
Practice Address - Country:US
Practice Address - Phone:208-625-3640
Practice Address - Fax:208-625-3645
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01002700363LF0000X
IDNP66228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily