Provider Demographics
NPI:1659149086
Name:GUNDERSON, KENNETH JAMES (FNP-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:GUNDERSON
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 1:1950 SAINT CLAIR RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6306
Mailing Address - Country:US
Mailing Address - Phone:208-569-8249
Mailing Address - Fax:
Practice Address - Street 1:1950 SAINT CLAIR RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6306
Practice Address - Country:US
Practice Address - Phone:208-569-8249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDF12230320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily