Provider Demographics
NPI:1912095563
Name:JAN SUND FNP,PC
Entity Type:Organization
Organization Name:JAN SUND FNP,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUND
Authorized Official - Suffix:
Authorized Official - Credentials:FNPPC
Authorized Official - Phone:208-733-6677
Mailing Address - Street 1:496 SHOUP AVE W STE C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5043
Mailing Address - Country:US
Mailing Address - Phone:208-733-6677
Mailing Address - Fax:208-733-6674
Practice Address - Street 1:496 SHOUP AVE W STE C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5043
Practice Address - Country:US
Practice Address - Phone:208-733-6677
Practice Address - Fax:208-733-6674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP282-A302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS71069Medicare UPIN