Provider Demographics
NPI:1013668847
Name:MERZLOCK, JUSTIN GREGORY (FNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GREGORY
Last Name:MERZLOCK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14926 W BRANDY LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5345
Mailing Address - Country:US
Mailing Address - Phone:208-251-5027
Mailing Address - Fax:
Practice Address - Street 1:4511 ZEBE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4707
Practice Address - Country:US
Practice Address - Phone:208-904-4780
Practice Address - Fax:208-904-4832
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID71322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily