Provider Demographics
NPI:1588609176
Name:ANTONIUK, NELSON (MD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:ANTONIUK
Suffix:
Gender:M
Credentials:MD
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 2160
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0908
Mailing Address - Country:US
Mailing Address - Phone:208-263-7101
Mailing Address - Fax:
Practice Address - Street 1:6509 HIGHWAY 2 STE 101
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-6609
Practice Address - Country:US
Practice Address - Phone:208-448-2321
Practice Address - Fax:208-448-1317
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13097207Q00000X
WAMD00040823207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine