Provider Demographics
NPI:1750827549
Name:PEARSON, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 W ANTELOPE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:ID
Mailing Address - Zip Code:83255-8754
Mailing Address - Country:US
Mailing Address - Phone:208-680-5339
Mailing Address - Fax:
Practice Address - Street 1:3551 W ANTELOPE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:ID
Practice Address - Zip Code:83255-8754
Practice Address - Country:US
Practice Address - Phone:208-680-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNS102890G343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID06142016715702Medicaid