Basic Information
| Provider Information | |||||||||
| NPI: | 1417241597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUPE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | MOORE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255085 | ||||||||
| FaxNumber: | 2086255731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 LINCOLN WAY | ||||||||
| Address2: | 315 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256000 | ||||||||
| FaxNumber: | 2086256001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2011 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M12445 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.