Provider Demographics
NPI:1770532780
Name:MORTIMER, MARGARET K (NP)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:K
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-322-7018
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-322-7018
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP349A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806976800Medicaid
ID806976800Medicaid
1344695Medicare ID - Type Unspecified