Provider Demographics
NPI:1740326990
Name:KUNA FAMILY MEDICAL CLINIC, P. A.
Entity type:Organization
Organization Name:KUNA FAMILY MEDICAL CLINIC, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:208-922-5130
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0068
Mailing Address - Country:US
Mailing Address - Phone:208-922-5130
Mailing Address - Fax:208-922-5132
Practice Address - Street 1:708 E WYTHE CREEK CT STE 103
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5005
Practice Address - Country:US
Practice Address - Phone:208-922-5130
Practice Address - Fax:208-922-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP193A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804073900Medicaid
ID804073900Medicaid