Provider Demographics
NPI:1760421051
Name:DECKER, BRIAN JOSEPH (FNPC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:DECKER
Suffix:
Gender:M
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 E 300 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5423
Mailing Address - Country:US
Mailing Address - Phone:208-403-4140
Mailing Address - Fax:
Practice Address - Street 1:3863 E 300 N
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5423
Practice Address - Country:US
Practice Address - Phone:208-403-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP616A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806669300Medicaid
IDNPXP9OtherBLUE CROSS OF IDAHO
IDP99441Medicare UPIN
ID806669300Medicaid