Provider Demographics
NPI:1629685235
Name:ROUBIDOUX, MARK MITCHELL II
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:MITCHELL
Last Name:ROUBIDOUX
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2768
Mailing Address - Country:US
Mailing Address - Phone:208-305-3537
Mailing Address - Fax:
Practice Address - Street 1:803 S MAIN ST # 320
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2695
Practice Address - Country:US
Practice Address - Phone:208-883-1008
Practice Address - Fax:208-883-4563
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39235363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care