Provider Demographics
NPI:1861473639
Name:MOSEMANN, MARK JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JONATHAN
Last Name:MOSEMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15622 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8710
Mailing Address - Country:US
Mailing Address - Phone:208-687-4878
Mailing Address - Fax:208-687-4879
Practice Address - Street 1:15622 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8710
Practice Address - Country:US
Practice Address - Phone:208-687-4878
Practice Address - Fax:208-687-4879
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMC-2296207P00000X
WY5756A146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW10088Medicare PIN