Provider Demographics
NPI:1548549249
Name:COLLEGE OF WESTERN IDAHO-MEDICAL EXPRESS CARE CLINIC
Entity type:Organization
Organization Name:COLLEGE OF WESTERN IDAHO-MEDICAL EXPRESS CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-562-2707
Mailing Address - Street 1:2407 NAMPA CALDWELL BLVD
Mailing Address - Street 2:NO. 168
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1515
Mailing Address - Country:US
Mailing Address - Phone:208-562-2200
Mailing Address - Fax:208-562-2207
Practice Address - Street 1:2407 NAMPA CALDWELL BLVD
Practice Address - Street 2:NO. 168
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1515
Practice Address - Country:US
Practice Address - Phone:208-562-2200
Practice Address - Fax:208-562-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP885A364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1740475680OtherNPI