Provider Demographics
NPI:1780497859
Name:NORTH IDAHO FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:NORTH IDAHO FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:BOZARTH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-770-8848
Mailing Address - Street 1:1101 E POLSTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6045
Mailing Address - Country:US
Mailing Address - Phone:208-747-1776
Mailing Address - Fax:208-747-1777
Practice Address - Street 1:1101 E POLSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-770-8848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-31
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty