Basic Information
| Provider Information | |||||||||
| NPI: | 1629047931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUEBLOOD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623251 | ||||||||
| FaxNumber: | 2089622313 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LEWISTON STREET | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623267 | ||||||||
| FaxNumber: | 2089623722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16906 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1623 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.