Provider Demographics
NPI:1790917789
Name:MUCKERMAN, JULIA LANCASTER (CNM, MSN)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:LANCASTER
Last Name:MUCKERMAN
Suffix:
Gender:F
Credentials:CNM, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-232-6100
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-232-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM 54A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife