Provider Demographics
NPI:1649266529
Name:KAUFMANN, THERESA MARIE (ANP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:KAUFMANN
Suffix:
Gender:F
Credentials:ANP
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 O
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-0049
Mailing Address - Country:US
Mailing Address - Phone:208-234-2001
Mailing Address - Fax:208-232-2195
Practice Address - Street 1:777 HOSPITAL WAY BLDG A
Practice Address - Street 2:STE. 101
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2753
Practice Address - Country:US
Practice Address - Phone:208-234-2001
Practice Address - Fax:208-232-2195
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP160A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806131600Medicaid
IDP38708Medicare UPIN
ID806131600Medicaid