Basic Information
| Provider Information | |||||||||
| NPI: | 1083816334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCHAN | ||||||||
| FirstName: | CAMERON | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 8TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833501535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084364322 | ||||||||
| FaxNumber: | 2084361312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 8TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084364322 | ||||||||
| FaxNumber: | 2084361312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP830A | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | NP830A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | M8073867 | 05 | ID | MEDICAID | NP830A | 01 | ID | NP LICENSE NUMBER | OTHER | N23998 | 01 | ID | RN LICENSE | OTHER |