Basic Information
| Provider Information | |||||||||
| NPI: | 1669858734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PACKER | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4168 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082392065 | ||||||||
| FaxNumber: | 2082393754 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391029 | ||||||||
| FaxNumber: | 2082393754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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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 | NP-1611A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.