Provider Demographics
NPI:1972716496
Name:LIDTKE, MARCIA KAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:KAY
Last Name:LIDTKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E EMERALD CT
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-8141
Mailing Address - Country:US
Mailing Address - Phone:408-813-0780
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-9656
Practice Address - Fax:801-373-2978
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9836853-4405363LF0000X
CA13626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00472864OtherRAILROAD MEDICARE PART B
CAZZZ06478ZMedicare UPIN