Provider Demographics
NPI:1598849051
Name:NORTHSTAR HEALTHCARE LLC
Entity Type:Organization
Organization Name:NORTHSTAR HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FNPC
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:208-529-2352
Mailing Address - Street 1:1995 E 17TH ST
Mailing Address - Street 2:STE 2
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-529-2352
Mailing Address - Fax:208-528-3332
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:STE 2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-529-2352
Practice Address - Fax:208-528-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP386A363L00000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806924200Medicaid
ID807185300Medicaid
DC1808OtherRAILROAD MEDICARE
ID1376852Medicare PIN
DC1808OtherRAILROAD MEDICARE