Provider Demographics
NPI:1457792277
Name:MCCONKIE, RICHARD M JR (NP-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:M
Last Name:MCCONKIE
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277976
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4740 N PENNGROVE WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7443
Practice Address - Country:US
Practice Address - Phone:208-514-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP 1302 A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner