Provider Demographics
NPI:1629047931
Name:TRUEBLOOD, JOHN DOUGLAS (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAS
Last Name:TRUEBLOOD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:208-962-3251
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON STREET
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-3722
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16906363A00000X
IDPA1623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant