Provider Demographics
NPI:1831290097
Name:URRUTIA, JOHN (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:URRUTIA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 FALLS AVENUE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-3181
Mailing Address - Fax:208-733-3168
Practice Address - Street 1:176 FALLS AVENUE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-3181
Practice Address - Fax:208-733-3168
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA336363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P81355Medicare UPIN
IDP81355Medicare UPIN
1667639Medicare PIN