Basic Information
| Provider Information | |||||||||
| NPI: | 1699819292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBLETTE | ||||||||
| FirstName: | THAD | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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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 | 363L00000X | AP60910202 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 59480 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1699819292 | 05 | WA | MEDICAID | 1699819292 | 05 | ID | MEDICAID |