Provider Demographics
NPI:1255510442
Name:MEDEL, DEBORAH WYNNE (NP)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:WYNNE
Last Name:MEDEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:DEBORAH
Other - Middle Name:WYNNE
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:213 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2700
Mailing Address - Country:US
Mailing Address - Phone:208-882-7565
Mailing Address - Fax:
Practice Address - Street 1:213 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2700
Practice Address - Country:US
Practice Address - Phone:208-882-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP593A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP89973Medicare UPIN